The darker side of being a doctor (2017) | Hacker News Reader

The darker side of being a doctor (2017)

drericlevi.substack.com

621 pointsm-ahmed500 comments

Something I've never quite understood is why, in the UK, we cap the number of medical students per year. I've known very bright people who aspired to be doctors but had their applications turned down only to go on to do phds and become scientists instead. I'd rather have twice as many doctors who work sensible hours rather than the status quo burn out. Looks like there are calls to change this. https://commonslibrary.parliament.uk/research-briefings/cbp-...

Supply and demand. If you artificially cap the supply of doctors, then the doctors can ramp up their prices.

I don't even think doctors want the cap, tbh. Your average emergency physician would take all the qualified help they can get.

Yes, but how many residents can each emergency physician train at once? Doctors are similar to apprentices for the last part of their training.

That explains why doctors like the status quo. Insurers like it, too, because expensive tests and expensive procedures must be ordered by a doctor (at least if insurance is going to pay for it) and if the patient gives up on getting in to see a doctor, then the insurer does not need to pay for the expensive test or expensive procedure. In the US, employers like it, too, because they end up paying the insurance premiums for their employees.

And the schools prefer it (at least in the US) - limited highly paid doctors means they can charge exorbitant tuition.

> And the schools prefer it (at least in the US) - limited highly paid doctors means they can charge exorbitant tuition.

What's the evidence for your position? Researchers who study this question have shown that the cost of medical education is significantly higher than the price assessed to students.

In other words, having more medical students would cost schools money.

I would've thought that the medical schools care about revenue, which is course can be increased both by raising tuition and by increase number of students.

There is an article in Le Monde diplomatique of February 2024 that briefly tells the story of the first numerus closus in France in the sixties.

Perhaps there's a little of that going on here in the UK. Doctors can certainly command a decent salary especially if they specialise, run private clinics etc. That said, I feel it's probably more complicated than that. Each place costs approx £230k (only £65k paid by student by way of loans). This means increasing supply is a costly endeavour. The government also says that they wish to maintain teaching and learning standards; although, I don't really buy that part.

Of course the UK government can avoid the training cost by hiring foreigners. From my personal experience maybe half the NHS doctors are from overseas.

Thank goodness we didn't make some insane political move that makes that harder then!

I'm not sure this really stands up in a UK context: https://www.nuffieldtrust.org.uk/sites/default/files/styles/...

Like he said, supply and demand. You are still at the mercy of what the customer is willing to pay. The customer will not pay an infinite amount, even for healthcare services.

But it is undeniable that doctors are paid considerably more than most other jobs. This is why.

Artificially limiting the supply of doctors is one way of rationing healthcare and holding down costs. Healthcare in the UK is largely funded through the NHS. Voters are already financially struggling and don't want to pay higher taxes. In some cases, even emergency patients are waiting hours in ambulances because hospitals are so overloaded.

https://www.bbc.com/news/uk-england-cornwall-68171254

Artificially limiting the supply of doctors drives the wages up. It's a common demand of doctors worldwide

Not if you're in the universal system where the government sets the payments.

I do know that limiting the number of doctors is one of many mechanisms to limit healthcare spending. A doctor can only see so many patients in one day.

I’m in Canada. If there were enough doctors that doctor unemployment was 2%+, like a normal job, doctors here would get paid less. Also doctors might not burn themselves out working crazy hours.

Instead, we have a dire shortage of doctors and people in government employed full time trying to recruit the limited supply.

Doctors can’t move to the next hospital for more pay, but they can move to the next province, or to the US.

Doesn't Canada (or maybe individual provinces) also have artificially imposed limits on how many new doctors there can be each year?

This doesn't make a lot of sense as an explanation for the policy—if there were more doctors trained that doesn't require that they find jobs, but it does make it easier for hospitals to replace their doctors if and when they need to, and likely at a lower price. If healthcare costs were the reason I'd expect the government to cap the number of doctors they employ now, not try to guess how many doctors they'll wish they could employ in six years.

> hospitals are so overloaded

How do you suggest we limit the demand for healthcare?

In the US, anyone can walk into the emergency room for treatment, but people who don’t have insurance are very unlikely to participate in preventative care.

The way to decrease demand For complicated and expensive interventions to preventable problems is to increase access to preventative care.

I'm not sure what you mean by preventative care.

In New Zealand "poor" might be a synonym for uninsured? However my peer group is middle aged professionals (not poor) with as variety of healthcare issues. Only a very few would preventative care help. Prevention would help many of my friends. A friend with a cancer scare that keeps smoking. A friend with gout that doesn't change habits. Multiple friends with issues from drugs that continue to take drugs. All my friends and me that are unfit and eat poor diets. I've given up drinking recently but I'm most definitely an outlier.

Prevention is often the cure.

Assuming you mean prevention when you say preventative care?

Prevention and preventive care are typically classified separately, although it's a bit of a gray area. US residents on health plans receive free access to preventive services including immunizations, screening tests, etc.

https://www.healthcare.gov/coverage/preventive-care-benefits...

But prevention is largely outside the scope of medical care. For issues like diet, exercise, and avoidance of substance abuse patients may be able to get help from a variety of other sources including public health agencies, therapists, social workers, dieticians, personal trainers, etc.

I support increasing access to preventative care, but I doubt that will do much to decrease demand. Currently about 92% of US residents have medical coverage, and that gives them free access to preventive care services which are proven to be a net benefit.

https://www.healthcare.gov/coverage/preventive-care-benefits...

But demand is increasingly driven by chronic medical conditions caused by lifestyle issues and local environments: obesity, substance abuse, sedentary lifestyles, toxin exposure, excess stress, lack of sunlight, etc. Those issues will have to be addressed through social policy rather than the healthcare system.

In the UK they severely limit access to any diagnostics, and your GP just gives you antibiotics and/or anti depressants.

At the hospital, they just classify your symptoms as “not critical”, refuse to admit you and kick you back to your GP, who then refuses to refer you for any investigations, I imagine because there is a gun to their head over targets etc

If your levels are high, you’re told oh it’s not severe. If it’s severe, you’re told oh it’s not critical etc

We have a system where everyone just gaslights you that you’re in fact not sick because you aren’t 3 seconds from death

That reduces access but it doesn't affect the demand for healthcare.

I'm in New Zealand: not a heap better than you describe. Here GPs are overworked and getting an appointment is difficult. The health system has waitlists to control access to a limited number of procedures performed in each specialty. You need to be healthy enough to pass the access requirements and for acute surgery you need to live long enough to get to the front of the queue.

Depends how you define demand. People who need and seek care, or just those who need care?

Some people absolutely don't bother seeking care because they know they'll be denied care without a huge battle

Because doctors' associations and regulatory bodies (like AAMC in the US) lobby to keep it that way to keep the value of their profession up.

And then make young residents work themselves to death.

> Because doctors' associations and regulatory bodies (like AAMC in the US) lobby to keep it that way to keep the value of their profession up.

This isn't true of the AAMC position in the US today, and when it was true in the 90s, there were many articles about an upcoming oversupply of physicians.

First, US medical school graduating classes are smaller in number than the number of available residency positions. So every year, the US is importing physicians trained in other countries.

Next, residency positions (required to practice in the US) are funded by the US government. You could readily contact your US representatives about the problem you perceive - if this a legitimate concern for you.

Additionally, US residency positions don't need to be funded by any government body, at all! Hospitals need 'simply' show that there is enough patient volume to support educating additional residents. This is another avenue where you can intervene, if this is indeed something you care about.

Lastly, 'advanced practice providers' are filling in large amounts of the deficits in physicians in primary care providers. So focusing on the number of physicians is to ignore the huge growth of NPs and PAs - some of whom can function without a physician in some parts of their practice.

I see many people blame 'the AAMC' for healthcare problems, but worry that not many appreciate the lack of a role the AAMC plays in the number of providers in America.

When was the over supply.

> When was the over supply.

A google search for '1990s physician oversupply' will give you many articles, like this one:

https://www.bmj.com/content/312/7026/269.1

Must've been nice

Not to disagree with any of your points, I'm skeptical of the proportion of NPs that can safely practice any medicine at all. I've met one competent PA, one PA who didn't understand basic human anatomy, and an PMHNP with a PhD who had seemingly no knowledge of pharmacology at all. Then I stumbled across some forums about 'noctors' with horror stories about real doctors taking patients suffering from malpractice by NPs.

> First, US medical school graduating classes are smaller in number than the number of available residency positions.

That's because the artificial restriction is placed on entrants to study, not qualified post-study graduates.

And it really is a purely artificial restriction: in the 90s, in SA, when affirmative action was implemented (where a C student from a particular background would get placed before an A student from a different background) didn't result in any measurable difference to the resulting quality of doctors.

We literally have a small experiment showing that allowing C students into med school doesn't affect the outcomes, and yet there is still a very limited intake into medical schools, and this is purely an artificial limitation.

The training of each doctor takes a lot of resources, especially specific numbers of cases necessary for each of the specialists who do surgery of any kind. If a surgeon does not do a procedure on a regular basis they lose skill in it and the less practice a doctor has had in a field, the worse their outcomes. So if you get 10 whipples in a year in an area and you have too many surgeons or hospitals taking less than 1 per year, without one getting more than a number of cases a year, all of them will be bad and your mortality will be high.

NHS is in a process of replacing doctors with physician assistants

Your own link contains your answer:

> Expanding the cap on medical and dental school places is complicated by the cost of training, current university and clinical placement capacity, and the current number of clinically qualified academic staff who design and deliver courses.

Furthermore, the NHS actually needs the funds to hire staff.

The core problem is that people are getting older with more complex health care requirements, that more and more conditions become treatable, that healthcare is often expensive, and that no one wants to pay for it.

I don't really feel it does. Sure I can see the costs involved complicate things. However, doubling the cap will likely introduce some economies of scale, surely that would reduce training costs. Also capacity would grow to meet training demand; Universities are always keen for more students. Also increasing the working pool will ultimately lead to more "clinically qualified academic staff". All this might become irrelevant with technology replacing GPs/Physicians. Perhaps in 10 years time we'll be examined by robots at our local pharmacy.

> All this might become irrelevant with technology replacing GPs/Physicians. Perhaps in 10 years time we'll be examined by robots at our local pharmacy.

lolno. Aside from the fact that AI is nowhere near good enough, we can't really build robots anywhere close to the dexterity required to do many of the physical actions. Also people like having human contact.

"Economies of scale" only works well for things like manufacture, and is much more limited for many other things. It certainly doesn't reduce the cost of actually paying a yearly salary to these people, or ensuring you have enough places (hospitals) for the to work at, which isn't cheap either. There are some small advantages one can take here on there, but in general, it scales fairly linearly. This is not just me saying that, your own link, again, says that.

Training 10 junior devs really is about 10 times as much work as training 1. Maybe slightly less because you can group some things, but not too much. And training 20 junior devs is about twice as much work as training 10.

It really is just a funding issue – which is what everyone has been saying for years. Labour wants to increase spots by abolishing non-doms – we'll see if that works when they win the election.

Otherwise feel free to stand for election and propose the n% tax hike required for all of this and see how well that goes.

I highly doubt that when I come with my kid who sneezes and have fever because half of his class sneezes and heads fever, the MD wold stop and think "ha, maybe he has a brain tumor or this entroprngiforitholzmosis that I heard about 37 years ago".

Not only Computer Aided Medicine would be a god send (it could help to duagnoze the entroprything above the MD forgot about, but would also help to leave the time for people actually sick with something an MD can help with

An associated problem is that bright people from rural or poor areas who are really passionate about being a doctor dont get the right grades to get in. Middle class kids in cities get in because its a good career but dont really like it that much and definitely dont want to work outside their city. My brother worked as a doctor until his thirties then quit, such a waste of training.

In Switzerland, at least for the french part, most of the doctors are not Swiss anymore. It literally became white collar immigrant job. Wife is one of those and sees the problem very clearly due to speaking about this with both (those few) swiss colleagues and the rest - its simply not attractive career path for locals, too much suffering and risk for relatively little reward.

Those bright enough go to law, IT and similar.

Speaking for my wife, she had to wade through absolutely brutal first 10 years for absolutely no good reason (she ain't no neurosurgeon, just internal medicine GP with FMH), no personal life at all at the prime of her life. 50 work week in contract (when average here is 42), reality with all required bureaucracy goes to 60-70, for everybody, consistently, unpaid (illegal here but who cares, state owns the hospital), often much more and catching up with tons of bureaucracy/billing at home.

Add night shifts, which most of us elsewhere have no experience with, that mess you up for many further days. You are a fraction of yourself, mentally and physically, for easily a week, more if you had to go through say 4-5 in a row.

These are the conditions that we put repeatedly people who have full control over life and death and health of their patients, often without further supervision, hoping they somehow magically never ever make a mistake, and when they do, folks immediately cry a murder and families sue to hell with massive dollar signs in their eyes.

You complain about that, or that you spend whole weekend being on call 48h unable to do anything really for literally 20 USD altogether (price of a canteen lunch here), including when you have to come and work 10-hour shift? You are put under pressure, shushed for being a pussy if you complain, told to toughen up since previous generations had it even tougher, and they somehow got through. Nobody mentions how horrible parents those absent folks were, how burned out they often were, quietly weeping or drinking themselves into oblivion. Well yes, those that didn't just quit, didn't go insane, didn't commit suicide, sure they got through. And now enjoy seeing young going through a bit milder version of the same. Of course there are insane amounts of money involved, but its always between insurance and hospital, doctors get less than capable IT folks for much less work. I am IT guy and consider this utterly fucked up wrong.

A good friend of ours sued the hospital (biggest public in Switzerland) for breaking basic Swiss law consistently like that, he was first but quickly gathered tons of other doctors. IIRC hospital finally caved in, a bit, but he is gone from it for good to private sector. Twice the pay, half the crap.

I could go on and on like this, a lot of doctor friends in our circles. It ain't some dream job, (at least a bit well-placed) IT job is a blessing in comparison.

/rant

I think its similar worldwide. Like I said my brother quit. Its also true that IT people are ridiculously overpaid. Both problems will inevitably revert to the mean.

Not everywhere though. The life of a doctor is much better in Costa Rica, even in public institutions. The extra time is paid. And the syndicates are strong (which has worked well)

The doctors in Nicaragua, the neighboring country, is as described in your comment, except the economy of the whole country is in shambles, and they also have to "voluntarily" participate in "government" political activities. Oh, and since the country is poor there are no immigrants waiting in line to fulfill those positions.

But Costa Rica has one of the longest wait times for non emergency surgeries.

https://www.oecd-ilibrary.org/sites/f8ac5867-en/index.html?i...

So high wait times there doesn't sound entirely perfect either.

Wouldn't this partly be a sign of markets deciding what wait time is worth it? For non-emergency surgery, like cataracts or knee replaces cited in the data, people can live with the conditions. It looks like wait times are consistent, meaning the backup isn't growing steadily over time. I'm pretty sure that would mean different populations just have a different threshold for how long they're willing to wait. If it was a consistent imbalance between the number of surgeries needed and the medical capacity I would expect to see wait times grow over time.

Perhaps this is related to the fact:

Cost of medical treatment and holidays included still cheaper than America?

Fits perfectly for non-emergencies.

Hey, there is a reason you can use Internet and this is us :)

It is not that IT is overpaid, it is that doctors are underpaid - at least in France.

We are the world champions of strikes and yet, somehow, doctors rarely go on strike. I do not know why.

They also know where they are going, it is not like they discover the world of medicine after 8 or 10 years.

I am happy that they are people who want to help others, but they also need to eat, sleep and party. Nobody will give them that if they do not protest.

If you're talking about the situation here in France, it's a bit different regarding money. Doctors are still paid more than most people in IT. Given the IT money in the US, I'm not sure they have the same situation if we look at the hourly rate.

Regarding doctors strikes, I asked the question to multiple ones and the few explanations I got are : - they are deeply regulated and organized, they rely more on acting behind the scenes (lobbying) than going public in the streets - they still have a comfortable situation that they chose ; unlike blue-collar workers who can barely afford food/housing and have to take what job and salary is offered to them ; a GP can move to a private hospital if they want more money and less hours - even though they are organized, they have much more individualistic views of their job than labor workers ; after all they mostly are their own company

I will have to look up actual numbers, but with 30 patients a day this is 25€x30x5x4=15000 a month pre everything. You take out taxes, costs, everything they need to pay in full and I guess the salary will not be very different from IT.

EDIT: I just looked up some numbers and you are right, MDs get about 5000€ net pour month in average, which is higher than IT

> Nobody will give them that if they do not protest.

Poland chiming in. Nobody will give them that even when they go out and protest.

> We are the world champions of strikes and yet, somehow, doctors rarely go on strike. I do not know why.

When talking about public healthcare, strikes mean little. State won't care unless the strike is massive enough to attract media attention. Hospitals can't close down, a "safe" minimum of workers must care for patients so not a big problem for the state generally.

Except if that safe minimum is on strike as well. It takes a coordinated effort, sure, but we have role models such as the train conductors or other champions of strikes

Absolutely not. Not all IT jobs & Doctor jobs are created equal. Entry-level roles might not warrant super high salaries in either case. Both IT and Doctor fields have a spectrum of jobs with varying pay scales depending on complexity and criticality.

> Its also true that IT people are ridiculously overpaid

Hard disagree here. I don't feel I need to state the reasons. If much of a business relies upon technology that the IT people ensure is up and running for the non-IT folk, I would say that is not overpaid.

This is such a shallow opinion with no forethought into the domino effect. I won't try to make a commentary on doctors, because I am not a doctor and don't pretend to say that "doctors are ridiculously overpaid" because I know it would be a wasteful opinion that does nothing for the conversation.

The picture you are painting is way too dark. And does not give a realistic picture.

A lot of what you say is true for doctors in their first 5-10 years into their career, when employed in a hospital.

This not true for doctors which reached a certain level like „oberarzt“ and above.

This is especially not true for doctors with their own „office“ (business).

Yeah people may cry, but normally it is very hard to bring a doctor to justice even when there are quite obvious mistakes or misconduct. They are very well protected, suing a doctor not seldom takes 10 years from start to verdict, with a lot of legal costs involved.

And last but not least, it is a very secure profession. You must be really really stupid to end up jobless. So you have 5-10 years with a „ok“ salary compared to the power you invest. And 20-30 Years with a very good to exceptional salary, especially when compared to the broader population.

> A lot of what you say is true for doctors in their first 5-10 years into their career, when employed in a hospital.

Then it's just semi-official hazing. It's still something that should be fixed.

Surgeon here, in private practice. Agree with the article - all the stressors he mentions are typical of both residents and staff physicians. The hour crunch for me is better post residency but overall the stress is unchanged. Probably higher after training with the added responsibilities & risks.

My sense is that the field developed in the era of independent/private practice, where the grueling hours worked was justified by high pay and minimal bureaucratic/administrative burden. Add decades of stagnant/falling pay plus death by a thousand administrative cuts and the profession no longer justifies the difficult working conditions as convincingly. Some practices are still good, others terrible. Look at the rate of physician turnover to see which is which.

Oh and the “provider” discussion is worth paying attention to. Your doctor has this calculus worked out - years & energy invested, work environment & income expected, then the only viable option in your city is to be employed by a large hospital system (because hospitals get paid at least double for the same work, outcome is as expected.) But wait there’s more: you are now called “provider” by your large hospital employer who hires 2x NP employees to do the “same” work as you and pay half. Guess what direction the pricing pressure is going. In the future expect few MDs to stay in primary care because the system does not support that path. Specialty training is the future for MDs who invest time, energy, & money to excel in their field.

I’m so glad I’m not alone in noticing this “provider” bs. Peel back the creepy Orwellian doublespeak and all you find is cynical ploy to save money by creating a false equivalence of doctors’ work with non-doctors. The health care industry is just the latest home of the money-grubbing vampire squid of finance. Sickens me.

Not sure how much you are actually in the business here, but almost everything you write is incorrect for literally every single doctor we know (cca 50, variously close, everything from GP to heart/neurosurgeons). You are clearly talking about German part, I talk about French, but still same general rules do apply.

Its trivial to sue a doctor, my wife, on her effin' first night shift in the country here got involved death of a patient and got into court case that took 6 months of court hearings to resolve. Not her fault, wasn't her patient even, but she still had to spent ridiculous amount of time for it outside work to get finally cleared.

Her colleague at this moment is getting sued, almost immediately after situation, for overlooking a cancer, when markers from test twice were non-conclusive (I don't/can't go into details, its a very complex case). Suing is very common here, its just that in case error can't be proved on their side, they have cca decent (and expensive) legal insurance. If they don't, license revocation, life-destroying fines, or even jail are on the table. Cases like this are common. This is very common for GPs with their own practice too, since they see more patients than some specialists.

Also not sure why you degrade other's people mental issues when under semi-constant decades of pressure from all sides. "Yeah people may cry" - this ain't how mental issues and burnout should be acknowledged. Please show some respect they properly deserve, you clearly are an outsider to profession and I sense some envy in between your lines. If its that bad with your life, go and start medicine studies, schools are open for anybody of any age and public schools here are free.

Last part - yes unemployment isn't generally high among doctors willing to work, but ie check canton Geneve now - no new GP licenses are granted (as = 0), and old folks are retiring fast. People are desperate to get a GP, I have colleagues begging me to find somebody via my wife for them, new doctors need to travel 2-3h every day to other cantons to find work, and some are properly desperate. As IT guy, I don't know a single capable colleague who has even similar employment issues, companies are always hiring good seniors, and there are tons of companies needing good IT folks left and right.

Same in Sweden, it is rare to meet a Swedish doctor at the 'vårdcentral' (group practice). In my infrequent visits with one of my children I've met doctors from Iran, from Iraq, from Germany and from the Netherlands but not from Sweden. Nurses tend to come from Sweden. What seems to happen is that Swedish doctors find work in e.g. Norway where the pay is a lot higher while the working environment is less stressful. That in itself is also a bit of an oddity since Swedish doctors don't see as many patients per day as those in e.g. the Netherlands do.

Potentially controversial opinion, but perhaps it is exactly the immigrants who are enabling the dysfunction to continue? I imagine tougher decisions would have been made to balance doctor quality of life with patient outcomes without immigrants taking whatever abuse the current system throws at them.

Ah, yes. Literal victim blaming.

They voluntarily immigrated to the country to take highly skilled jobs and are free to leave at any time. They are not victims; they are willing participants in an exploitative system.

People with limited choices can still be victims even if they volunteer.

You're kinda ignoring the part where the exploitative system is global, and those people are coming from places that are on the more exploited end of it. The reason why they come to take those jobs is because of the quality of life that comes with that, that is impossible to achieve in their home country. And the reason for the latter is largely because their countries have historically been exploited by the one they're now coming to, and in many cases, are still being economically exploited in various ways (including directly sponsoring local political corruption by foreign businesses). If you don't want them to come to your country to chase a better life, raise the living standard in their country.

The governments set the immigration policies. They probably think it’s easier to import doctors than fix the problems with medical schools, hospitals, doctors guilds, payment systems, ect… It is very uncharitable to view this as an attack on immigrants.

If you allow the capital class to import new workers when the current batch get too “uppity”, why would you expect conditions to improve?

This is happening across society, and I consider it a tragedy the people focused on race and sex have taken all the oxygen out of the room for a much needed discussion on class.

I’d even go so far as to say it’s encouraged (eg, BlockRock ESG) as part of a “divide and conquer” strategy by the capital class.

This is getting downvoted like it is some horrible bigoted remark, and I don’t think it is. It seems reasonable to me to say that immigration can paper over problems.

Are you suggesting that the solution is that immigrants just make better decisions?

If you're on a work visa and need a employer to sponsor you to stay in the country, it's pretty hard to quit if you're being taken advantage of. Being ineligible for unemployment payments or other support doesn't exactly help. Immigrants are often making the best decisions they can given the constraints of the situation, but it's not good for them or for local workers if immigrant workers are an exploitable underclass.

While somewhat rudely expressed, but in principle I'd agree. There are people who call it modern day imperialism – it's the draining high performant brains from other countries what allows western societies to keep doing a lot of things.

As an immigrant myself, I've heard this take a lot. I despise it because it treats us as a resource that you can allocate here or there as needed to solve problems, ignoring the person themselves and their needs and wants. What if the "high performant brain" does not want to sacrifice their own well-being for the sake of "improving their country"?

If "anti-imperialist" Westerners truly care so much about brain drain negatively affecting other countries, they should go live in those countries themselves and provide their services there for the sake of greater good. But very few actually do so, and even fewer are willing to do it on any kind of non-temporary basis.

Don't be offended. I completely understand that in personal level the view is very different. It's normal that in personal level you make your own choices and choose whatever is better for you personally. But it doesn't mean that a lot of people choosing whatever it's best for them are creating outcome that's better for the world.

PS. I didn't say that people calling this imperialism are from west.

    > too much suffering and risk for relatively little reward.

Is the pay as high as the US? Specialist doctors have crazy high salaries in the US.

We should enforce rigorous qualifications for doctors. We've relaxed the standards far too much already.

Qualifications should come at the end of your education, not at the start.

Educating doctors is really expensive. It would really suck to invest all that money in someone (or in yourself) just for them to fail a final test or whatever.

For what it's worth, I do agree we should train more doctors, but I think it's a complicated problem.

> Educating doctors is really expensive. It would really suck to invest all that money in someone (or in yourself) just for them to fail a final test or whatever.

This happens already, today. There are dozens of reasonable questions you can raise based on this fact - but I don't think it's obvious that the failures at the end of training can majoritarily be identified by pre-training metrics.

Some countries allow any student to take the first two years of medical courses, and then impose restrictions on the following years. This seems a relatively fair system; you can imagine someone persevering over many years to attain the requisite knowledge - but this person would not have had the opportunity if there were a pre-medical school filter

We do not need all doctors to be uber doctors.

We need a range of doctors, who range in price according to quality.

That way for simple stuff, which anyone can get right, we go to a cheap, reasonable doctor.

A similar example would be if we only had uber software engineers. Each one had to have a PhD. There were no cheap and okay developers who could do say web-sites but not write a programming language from scratch.

I think you're possibly describing nurse practitioners?

Or maybe more of a "doctor minus" rather than a "nurse plus" system.

A Physician’s Assistant (PA) is exactly that.

Yes they are describing NPs and PAs. MDs are the PhDs of the medical world. Don’t get me started on “DNPs”

That is not even remotely viable. There is little or no correlation between price and quality in healthcare. There are no reliable ways to accurately measure quality of individual doctors across the full spectrum of services that they deliver. In particular, it doesn't make sense to just look at outcomes because the doctors who take on more difficult cases will always look worse in the metrics regardless of the quality of care that they deliver.

Your example doesn't even make sense. Having a PhD doesn't make software engineers more productive on average. PhD programs train researchers. Research skills have very little correlation with practical software engineering.

What could actually work is to train more physician assistants and nurse practitioners, then have them deliver the bulk of simple primary care services under the supervision of physicians. This is more cost effective and usually works well enough, although there may be some degradation in service quality for edge cases.

Like air transport, in America Healthcare has its First Class, Business and Steerage tiers of medical care.

ACA (Obamacare)HMOs may have opened healthcare up to a lot of people who until then were going without. But its a faaaar cry from from Employer PPOs. And the ACA PPOs somewhere in between.

An don't forget the Trumpcare policies, with major policy exclusions.

I've heard this before, but I still can't figure out where this first class medical care is hiding. For the regional medical system I'm familiar with, there are two major hospitals, each with a set of associated providers. They both take most "insurances", because they effectively have to. I'm mostly familiar with the "better" one, and my experiences there have not been good. Are they checking the class of a patient's "insurance" plan behind the scenes, and sending different doctors based on that? Do I need to travel to a major 1M+ city (somehow even during an emergency)? Or what else gives? Where are these engaged doctors, who actually give you more than a 10-20 minute slice of their time, actually hiding? Ones who don't simply pass the buck to a different place (often booking many months out), recursively? Because from what I've gathered, I suspect that most people are just not very good at judging the competence of professionals, and are absolutely unable to judge the constructive incompetence of systems.

You appear to be mixing up a number of unrelated issues. Employers often offer both HMO and PPO plans. The differences are typically in provider networks and deductibles/co-pays/co-insurance. Employer sponsored PPO plans don't necessarily make it easier to access higher quality providers — especially because most of the metrics for measuring provider quality are unreliable or even misleading. And in practice there is very little difference in networks between most health plans; the majority of major provider organizations accept all the major plans.

If you really want "First Class" health care then you'll have to pay out of pocket for concierge medicine. That isn't directly covered by most insurance plans, although they will reimburse for certain services delivered through concierge medicine practices.

Lol. Vary by price? This screams USA. Cost, even of labour, is very much disconnected from patient outcomes.

I would say to you that in the normal case, in general, across all fields - bicycles, clothing, tables, chocolate, holidays, houses, butlers, what-have-you - cost is related to outcome, and this is what would be expected.

In the normal case, I would then think that cost in medicine and medical services would be related to outcome.

To the extent this generalization is true, then when cost is not related to outcome, this is not a normal situation, and then the question would be "why?" - what's going on to make a situation which on the face of it is not normal.

Well what we are learning is that we don’t need doctors for the simple stuff. The doctors cap honestly make sense. We have a surplus of generalists who still do not understand the body systematically, so the demand is not there

If the demand is not there, why is a cap required?

If the demand is there, why is a cap imposed?

Seems it comes down to: "budget-minded politicians in Congress"

According to 'studentdoctor.net' from 2017 - there is a cap because there are not enough residencies for graduating med students. The government is the primary payer for residencies: "It was because of the cost of GME funding that this program came under the fire of budget-minded politicians in Congress. This resulted in curbing of funding for residencies under the Balanced Budget Act (BBA) of both 1997 and 1999:" [1]

> The limitation in funding has essentially put a cap on the number of residencies that can take place in the United States – and since a doctor cannot go into practice without a residency, this is essentially a cap on the number of new, American-trained physicians who are allowed to practice in this country. The American Medical Association, in its AMA wire, blames this cap for the record number of students in 2015 who were not matched with a residency program at the end of their four years in medical school: of the 18,025 allopathic seniors and 3,000 osteopathic seniors who participated in the Main Residency Match, the two groups matched at rates of 93.9% and 79.3% respectively, leaving the highest percentage ever unmatched – and also unable to practice on their own.

> There are proponents for keeping the current cap in place, however. This is mostly among budget-minded members of Congress who are wanting to cut spending, but even the Obama administration proposed reducing Medicare expenditure on GME, even halving support for children’s hospitals, which have their own separate sources of funding. People on this side of this issue tend to decry the seriousness of the physician shortage, pointing out that the increase of physician’s assistants and advanced nurse practitioners has helped to mitigate this problem, even with the cap still in place.

The resource [1] is a bit dated. "Congress recently took steps to support several programs supporting GME funding by fixing technical issues that left some rural programs with an inadvertently low cap, expanding eligibility for rural training track funding, and adding 1000 new Medicare-funded positions for the first time since 1997. " [2]

[1] https://www.studentdoctor.net/2017/01/24/medical-students-kn...

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8370355/

> We have a surplus of generalists who still do not understand the body systematically

How is this synonymous with not specializing?

Have we though? You got any source on that? There's already a severe shortage of doctors, so what happens if standards are significantly increased?

Having a doctor available to treat you at all is still much better than having your very high standards and then not having a doctor available period.

I suspect that, after some point, making the qualifications stricter actually drives away many of the best candidates.

I doubt it. They pay is high enough to attract more people than necessary. Most ultra high income jobs are the same.

Being a doctor is not a reliably ultra-high-income job, and many people don’t consider the slog of med school, an internship, a residency, and an eventual possible job at a hospital to be worth any amount of money.

Sure, but no doctors is worse than lower skilled doctors as even lower skilled doctors are better than the average patient self-treatment attempt.

We need doctors who are available to treat simple conditions and refer to a more qualified doctor for the complex ones. Such a job doesn't require being a genius, just people who are not complete idiots, and the qualifications required here are genius-level, not idiotproof-level.

I don't know, lower skilled doctors can be quite a pseudo science amplifier at worst. Sometimes it does feel like that no doctor is better lower skilled one, especially when self treatment (or more accurately, remote treatment) is getting better nowadays.

The problem is worse when there is a lack of actual doctors.

It people can't see a doctor, or can't get decent care because doctors are overworked, they will go to the "pseudo doctors". "pseudo doctors" are usually much less regulated, because they don't really practice medicine, can't make prescriptions, are not covered by healthcare subsidies, etc... but they are available, and actually caring, because there is no shortage of them.

This is actually good for the patients, sometimes, all you need to get better is someone who listens to you and points you to a healthier lifestyle something, something that "pseudo doctors" can do well. The problem is when they bring their pseudoscience to "treat" actual medical problems that can't just be solved by eating vegetables and getting some rest.

Now imagine an actual doctor who is available and caring, giving you all the benefits of the "pseudo doctor", but in addition, can actually practice medicine. Maybe not to the highest level, but he would have attended an actual medical school and knows enough not to treat cancer with fruits.

The problem now in many places is that it is not just hard to become a doctor, it is hard to access medical studies.

No real doctor will be caring, because he has no time for that, the way the system is currently.

Sounds like we need something between nurse and doctor. Or is actual nurse already suffice for this?

https://en.wikipedia.org/wiki/Nurse_practitioner is a title I've seen.

So what's the drawback of this? Because otherwise this sounds like what's actually needed.

    > We need doctors who are available to treat simple conditions and refer to a more qualified doctor for the complex ones.

This is most medical systems work in highly industrialised nations. First, you visit a GP. If necessary the send you to a specialist.

this is completely wrong. there are not enough doctors at all levels. not everyone is going to be a brain surgeon.

What sort of qualifications? 99th percentile talent in subjects like organic chemistry, which are actually not used by 99% of doctors in the real world? Willingness to work themselves so long and hard that their judgement is usually substantially impaired?

And does the (my impression) widespread support for oh-so-rigorous qualifications for doctors reflect any real-world data about actual resulting quality of patient care? Or is it a way for prospective patients to vocalize a bunch of anxieties and emotions about medical care, plus a way for the doctors who've had to endure such treatment to say "all the noobs should have to suffer as much as I did"?

If your doctor is more clueless than you that speaks of itself.

Why did he quit? Burnout? And what career did he switch to?

> An associated problem is that bright people from rural or poor areas who are really passionate about being a doctor dont get the right grades to get in.

This is unlikely to be true.

If I think about it.. it's unfortunate that access to medical education and careers can be limited by factors such as socioeconomic background or geographical location... If I understand correctly

idk why doesn't my startup hire twice as many people? wouldn't we get the work done twice as fast and make twice as much money?

With doctors you can parallelize treating different patients pretty easily.

Training places are already rammed to the gills, there aren't enough places to put substantially more students. Junior doctors already have to compete to get training slots even vaguely where they live and if they miss that they simply have to physically move to a different city. Medical training isn't as simple as just adding a lecture theatre and a few classrooms, or even a whole university building faculty of lecturers and admin. You also need a hospital (and GP surgeries etc) to be attached as well as enough senior staff to train them when they are there. That training is very intensive on trainer:trainee ratios and the senior staff are also in critically short supply as the ones who were trained up when there was training capacity (which, to be fair, was a time when it was far cheaper to train a medical student), are retiring by the thousands and many newer junior doctors quit or emigrate as a result of their experiences up to that point.

Hospitals cost absurdly large amounts of money, especially in the UK where there are consultancies and layers of subcontracting for everything. So the infrastructure costs of adding even a few hundred student places is astronomical.

Due to strategic underinvestment (or ideological sabotage, or governance incompetence, depending on outlook) there is now a self-reinforcing problem: not enough hospitals and staff to train doctors to beef up existing hospital staffing or work in hypothetical new hospitals even if a money firehose was turned on.

Rather than having a tall glass of concrete and doing the hard thing, which will still take decades to manifest, what the government is currently doing is a rerun of Healthcare Assistants where more care is delegated to much cheaper-to-train staff. Plus quite a bit of noise about "AI" bring used to allow them to sweat the asset of the staff they do have by, for example having one radiologist verifying AI findings rather than a pair-based system.

Which will all work "kinda ok" and let them punt the problems at least into the next government's domain when they lose the next election and can spend 5 years screaming from the Opposition benches about the mess. But you cannot do it forever (or the hail-Mary works, there's an AI revolution and you can actually run a hospital with an app, 2 agency nurses, a few smart plugs and an AWS instance).

Of course "doing the hard thing" would be easy to say if it was just the NHS, but there's the same structural degradation in everything. So you also need to spend billions on education. That's the same general problem - shortage of facilities and not enough existing staff to train new staff and the ones you do train quit. Schools are currently one something like a near-500-year replacement rate (50 per year, 24000 total) and that's without considering population growth or even the hundreds of schools that need rebuilding because they're made of RAAC. Then roads need billions to repair the accumulating damage. The railways need huge investment and staffing. Energy is the same - virtually no supply of domestic nuclear design engineers mean they get absolutely rinsed on even squinting in the direction of a drawing of reactor (though Hinkley Point C cost spiral is currently EDF's problem, not the taxpayer and green energy is actually a rare success story). Defence is similar (e.g. ships being retired because they need the staff elsewhere). At least some water networks are collapsing into a multi-billion hole after private dividend extraction. So that money firehose has a lot of work to do, even if they would turn it on. Which is ideological poison apparently.

> Medical training isn't as simple as just adding a lecture theatre and a few classrooms, or even a whole university building faculty of lecturers and admin. You also need a hospital (and GP surgeries etc) to be attached as well as enough senior staff to train them when they are there. That training is very intensive on trainer:trainee ratios and the senior staff are also in critically short supply as the ones who were trained up when there was training capacity (which, to be fair, was a time when it was far cheaper to train a medical student), are retiring by the thousands and many newer junior doctors quit or emigrate as a result of their experiences up to that point.

All easily solvable:

1. * You also need a hospital (and GP surgeries etc) to be attached as well as enough senior staff to train them when they are there. *

Only for the final 2 years of a total of 7 years of study, which means if we ramp up entrants for 2025, the extra new facilities need to be ready only in 2032.

2. * That training is very intensive on trainer:trainee ratios and the senior staff are also in critically short supply *

Not a problem for a career which is regulated with a national body - simply enforce a minimum number of hours of teaching/mentorship per year to renew mambership of that body. Since the full capacity will only be needed by 2032, this can be done progressively over 7 years.

3. * are retiring by the thousands and many newer junior doctors quit or emigrate as a result of their experiences up to that point.*

Simple: you currently don't get to qualify as a practicing doctor simply by passing exams, so withhold certification until a minimum time has been spent in mentorship/public health services.

My life experience showed me that allowing more people in lead to less capable people in. Less capable students graduate as worse doctors. And doctors who came from more wealthy families usually do much better, regardless of their prowess. I won't go into details, it is unnecessary.

The end result is that the health practice degrades overall, and social inequality strenghtens. I think nobody is happy with the former reason.

The standards have gone up considerably compared to 20 years ago. I'd say return to the standards of 20-40 years ago at similar admission rates , remove leetcoding equivalents such as volunteering in Africa and A++ on organic chemistry (which you never use at an A++ level as a doctor) and everything will be just fine.

I haven’t downvoted you but I’ve actually found the opposite to be the case.

I’ve come across quite a few medical doctors who seem to lack the ability to listen to their patients – or the interest in investigating the cause of problems. I got the impression that they came from wealthy backgrounds and are the type of people who do well in exams and became doctors purely for the monetary return and social prestige. It’s disappointing to realise that I, as a system administrator, put more effort into investigating and solving IT problems for co-workers than some doctors put into investigating serious medical and health problems.

On the other hand, I’ve met a few intelligent, gifted and empathetic people who really wanted to be doctors or nurses but weren’t so good at rote memorisation. As a result, they didn’t obtain the necessary “points” to get one of the very limited places in medical courses.

one reason is to make sure that the best and brightest are distributed amongst different industries.

In many countries they have a cap of the number of medical students. You might want to check what is happening in Korea rn.

It's the same in the US, Italy, etc Doctors are a cartel receiving a monopoly from the State. That's all there is to it, really

but.. why?

It’s extremely beneficial to the people who are already doctors (dramatically increases salary, prestige, power), and that is a powerful group in most societies.

Also, being a coveted occupation ensures that there will always be a pool of people fighting for it. Scarcity drives demand.

Not always.

If I sell garden gnomes wearing knitted hats, but I only make three a year and sell to only people who drive yellow cars, I doubt I could earn a decent living off this

Don’t be obtuse. You’re comparing garden gnomes with healthcare.

I mentioned garden gnomes as an example of how supply side economics and “scarcity drives demand” doesn’t work.

The post you replied to scoped their statement to „coveted“ applications. No one actually believes scarcity drives demand in all cases.

The grammar of the sentence, as written, would really indicate otherwise. Written in the post: "Scarcity drives demand." (exact quote)

The sub-text is that doctors are slightly corrupt and wish to be payed more, and therefore are incetivized to reduce the total number of doctors.

After reading the travails of what this doctor is going through, that seems like a very callous take, insulting even.

It’d be callous and insulting if it was a reasoned position.

IDK if needs to be reasoned or not. I'm imagining someone making these comments to the author's face after having been read the article. The 'callous' part comes from disregarding everything in the article to go on some great tangent about the AMA and artificial scarcity of doctors.

What's more, it seems that this article has triggered a reflexive anti-union stance, when it's more a hallmark of a place where capitalism does not work well. Why doesn't that hospital have more doctors? Surely, they could have found someone additional if they wanted. The hospital did not have to schedule every surgery as if they all required the average procedure time. The hospital could invest in better IT infrastructure and have software that was not a drag to use. Surely the hospital could have someone help the doctor not make 70+ calls over the course of a shift in addition to everything else they do. This blog post is not about a general scarcity of doctors; there's lots that could be done by the hospital investing in its staff and outcomes without hiring a single additional doctor.

Being a business means they have to optimize for profit (to at least some non trivial degree), or die.

Many hospitals are run by non profit organizations to help reduce this problem. However even they cannot run at a loss overall for long. Bankruptcy doesn’t help anyone actually provide services, after all.

Gov’t has different incentives - but then care is strongly controlled and limited by public policy, for better or worse.

And an organization that is able to optimize to produce more value than they consume (aka is more profitable) can take more risks, expand better, have more capital to invest in training, equipment, etc, be more competitive in who they hire, and have better and more comfortable facilities if they want.

And being a Dr. can be really miserable sometimes, and the training is also really hard and miserable.

Some (surgeons, esp. plastic surgery) optimize for maximum $$ for misery, usually. Others (pediatrics) optimize for maximum ‘feel goods’ for misery, usually. Most others are somewhere in between.

Either way, if they didn’t want/need the money, they’d be going to medicine sans frontiers or working in rural medicine eh?

Skipping some quibbles,would you agree that some optimizations for profit would lead to business death?

Eg, businesses that cheat and get caught. Businesses that over consume and can no longer produce.Also, that optimization can have the opposite effect. Eg, optimize revenue by showing max ads, with max ads users start to flee. A hospital could optimize for patientoutcomes, and then do better because the patients stay around.

This overall though assumes that free market principles work in healthcare. Those principles tend to assume consumer choice.

Don't be a pain. All analogies are wrong, but they can still be illustrative

So beneficial that they commit suicide?

The people who organise scarcity find it beneficial to themselves, but obviously it doesn't mean all doctors, or even most them, like this situation.

But the article is about burnout. Surely that can't be great for existing doctors, either?

They choose more money over avoiding burnout.

You took the words right out of my mouth! Money is the elephant in the room here. Why doesn't the author quit surgery and start a small GP clinic? Oh, only half the pay? I see similar behaviour in law firms and investment banking.

So the answer to being overworked in a hospital is to quit, be overwhelming running your own business for half the pay?

That doesn't make any sense. And not everyone has the capital or capacity to make their own business

Let's not pretend we're talking about the difference between $30k and $60k/yr here. We're talking about $400k vs. $800k. "I'll only make half a million dollars a year if I do this" does not set oneself up to be a sympathetic character.

In what world is your typical surgeon paid $800k/yr?

In the US a lot of surgeons make this much or more.

The enforced scarcity in the market is what makes sure the money is always enough to prevent you from relaxing. Imagine doctors were as common as McDonald's managers. At the margin doctors would frequently be taking a slight cut in pay to do something fun like sports medicine. Now imagine there was only one doctor in the world. Even if he longed to relax and do pharmacy, ailing kings would offer him mountains of gold until he almost had no choice but to see them.

You're not wrong about the financial aspect but remember surgeons are completely incapable of being GPs. Surgery is its own residency (5 years I think?), and to be an actual GP you have to be either a family (3 years) or internal (4 years) medicine residency graduate. So in addition to the pay cut in absolute terms, you're taking 3-4 years off and making $60k/yr working 80+ hour weeks to do that other residency. So the opportunity cost alone is a few million even ignoring the pay cut.

Presumably, those who trained as surgeons, want to be surgeons. Sunk cost fallacy might come into play. A better analogy is someone who wants to be a software engineer, get burned out - and you say "hey, why not be a NOC technician if you can't handle it?"

Further, you assume a surgeon could just become a GP. They are different fields.

https://www.quora.com/Can-a-surgeon-also-practice-as-a-prima...

"Can a surgeon become a regular doctor?"

> They can try. But they would have no idea what they are doing. But legally, they could certainly practice as a primary care doctor. They would not be board certified, and could not sit for the ABIM exam, and would not be able to pass it if they did.

> The professions are also very different, primary care is more allied to the work of a physician, whilst a surgeon is trained to do serious surgery, not the kind a primary care doctor would do. So not sure even if you could be legally certified in both specialties you wouldn't loose your surgical skills if you spend a lot of time in primary care.

> Knowing what I know about the medical world in general I would advice against such a combination, a surgical residency is such a taxing one that you wouldn't have time to do anything else beside surgery, furthermore the required mental approach to do the work well as a surgeon or a primary care physician is also quite different.

I don’t think many doctors have much choice in the matter. The MBAization of hospital companies and practices bought up by private equity is strip mining the productive capacity of providers to juice profits. This is the MO of financial capitalism: find an established business that someone else built and extract maximum profits until the business collapses, then leave the rubble for others to clean up.

I think it comes down to, if you read the history of the American Medical Association, that some doctors simply didn’t like a free market pushing down prices for their services.

then again, who does

In this case, people who rely on health services to live probably do.

The point was nobody likes their own salaries being depressed due to the free market. One difference is that doctors even under very free market conditions enjoy high salaries so it's comparatively pretty easy for them to set aside some money to lobby to tighten up that market - which gives them more money, which makes it even easier to ...

Yeah, but why is the same situation present, and the same explanation given, in Poland, EU? Or, seeing from other comments, plenty other countries around the world?

I'm seconding 'viraptor here - this isn't a good enough explanation. It doesn't stand up to scrutiny, and doesn't mesh well with day-to-day experience. Individual doctors I know seem to have very little influence over anything, and they're first in line to the protests about working conditions and pay.

There are a few factors:

1. Doctors have a lot of political influence because they are popular. This means they can get away with things that other industries mostly can't.

2. State provision of medical care corrupts the system, as I describe sidethread: https://news.ycombinator.com/item?id=40030452

One way to drive "medical costs" down is to ensure that the supply of medical care is low. This also drives prices up. This means that the incentives of the regulatory body are directly contrary to the incentives of the people supposedly benefiting from the regulation.

(And doctors and hospitals are happy with this, because such a system boils down to telling them "we want you to do less work, but for more money".)

3. (Tangentially, note that the general model of "restrict supply, subsidize demand" is incredibly common. It's popular both ways; the first part helps a small but politically active and highly motivated group, and the second part pretends to help the populace in general.)

> 2. State provision of medical care corrupts the system, as I describe sidethread

How is this at play (from the article we are commenting on)?

The article does not mention once: "medicare", "medicaid", "regulation", "law", "government" - once.

If anything, it's the inverse. You have it bass-ackwards, the private hospital, the for-profit system is driving things like:

> I delivered my third child with my own hands because the obstetrician was stuck in a traffic jam. The following morning I went to work because if I didn’t 12 patients have to miss their surgeries, 2 anaesthetists and about 8 nurses will miss out on their day’s income. More importantly, admin would not be happy because a cancelled operating list is a huge financial loss to the hospital.

----------------

> 1. Doctors have a lot of political influence because they are popular. This means they can get away with things that other industries mostly can't.

Can you clarify how this doctor exerts any type of political influence? They have a sleeping bag in their car they sleep at their job so often and are lamenting they barely get to see their family. I don't see your point at all being illustrated in this article, at all.

---------------

> "And doctors and hospitals are happy with this, because such a system boils down to telling them "we want you to do less work, but for more money".

I get the feeling this doctor is on the verge of suicide from being over-worked. Do you think the person that wrote this article would agree with your statement?

Those might be better arguments if this doctor were personally setting the medical school admissions quota, but I'm pretty sure he isn't.

Not personally, no, but in many countries the professional organizations representing doctors do lobby for exactly that.

To the contrary, it would be strange if other mixed economies were somehow immune to this. There's a reason agricultural subsidies are corrupt in both the US and EU, and why zoning laws are a problem in both the US and EU. The same incentives will lead to the same outcome.

I'm not sure that's a good enough explanation. There's minimal if any impact from a given doctor on country wide policies, especially the ones funded by state. Junior doctors in the UK couldn't push basic improvements to both their working conditions and pay. That doesn't seem to match the idea that they can meaningfully influence the doctors intake numbers.

I don’t know about other countries but that’s absolutely the case for the US.

The culprit is the AMA.

> In the 20th century, the AMA has frequently lobbied to restrict the supply of physicians, contributing to a doctor shortage in the United States.[10][11][12] The organization has also lobbied against allowing physician assistants and other health care providers to perform basic forms of health care. The organization has historically lobbied against various of government-run health insurance.

https://en.wikipedia.org/wiki/American_Medical_Association

Obviously, they are a big problem, but they're not the only problem. It is received wisdom among doctors that increasing the number of doctors causes medical costs to go up, and it is generally also the position of the state.

The doctors are simply wrong; the state is correct from a pernicious point of view.

Because the state is responsible for buying so much of the total supply of medical care, they generally view things from the perspective of "how much are we spending on the category 'medical care'?", rather than the perspective of how much any given treatment costs.

Increasing the number of doctors lowers the cost of all treatments and is unambiguously good.

However, it does raise the total amount of medical spending, which, in the eyes of the state, is bad.

So you’re saying that increasing the number of doctors will result in more medical services being consumed which means higher costs for the gov?

That’s the view of the government?

Yes.

Think of it like increasing lanes in a highway. [https://en.m.wikipedia.org/wiki/Braess%27s_paradox]

Or induced demand.

That said, likely individual medical outcomes would be better.

Large scale systems tend to produce… odd behaviors.

Milton Friedman discusses this in depth in his book Free to Choose (from the 1980s), for anyone who’s interested. Here we are 40 years later, problem still unsolved.

Wow.. amazing

In the U.S., sure. But in the UK status of a doctor is akin to that of a schoolteacher. Totally not a highly sought-after, profitable career like it is in the U.S.

Doctors are paid a lot more than schoolteachers in the UK and in my experience are respected because of their profession. I think you're totally incorrect.

Seconded. My perception is that here in Britain, medical doctors are highly respected, and pretty well paid. This is different from the US, where medical doctors are highly respected and extremely well paid.

Prestige is, of course, not a function of income alone. Plenty of software developers get paid at least as much as respected professors or top military brass. That doesn't mean they have equivalent prestige.

This makes sense in the IS, and the AMA does indeed try to limit the number of graduating medical students. But in the UK most doctors will work for the state where they are all on the same pay scale (I think) so a lack of supply shouldn’t be expected to push up the price of labour much.

One reason you could imagine is that the health trusts determine roughly how many student doctors they are able to train and then the government limits graduation rates based on this. But I don’t know if that’s the actual reason, and it could be a half-reason, eg the number was set a long time ago and not updated.

And training doctors is very expensive. This is subsidised by the state through capped tuition fees. Plus to train a doctor you need enough doctors for junior doctors to train the junior doctors presumably.

In the UK, the NHS primarily exists as a mechanism for rationing medical care. If you compare how much every industrialized country spends on medical care, there’s a very strong correlation with GDP—the richer a country is, the more money they spend on medical care, and the higher proportion of GDP goes to medical care. The UK is uniquely below this trendline, indicating a de facto policy of artificial rationing.

Well, compare the trajectory of doctors to factory workers as career paths.

I think you’re giving way too much credit to medical associations to rig the game in their favor. They exert enough influence over all fifty states and the various private institutions to systemically deny training to qualified candidates?

The fact is it’s extremely expensive and time consuming to train physicians. There isn’t enough space. Third and fourth year med students are going to far-flung hospitals to have hands-on experience because staying in the larger cities means they’re competing for access to training with residents.

All of this factors in to the cost and limited space of med school classes. It’s sad, but we would have to reinvent how we train physicians to address the limitations.

You just spend more money to scale the program. Funding for the residency program has been frozen since the late 90s, the demand for doctors has not been.

You can't "just" spend more on residency training without also "just" making med school classes bigger. You can't "just" expand med school classes without "just" increasing teaching staff, who are 9 times out of 10 physicians themselves. And very few physicians are going to willingly turn down $500k/yr clinical jobs to teach for a fraction of that.

You’re describing problems that are all solved by money.

And time. You double the number of residency slots but it will take years to fill them if you increase med school size at the same time, a type of coordination that is very unlikely.

30 years is a lot of time. I agree with GP. Starting back then would have been best; starting now would be second. I live in a country that has twice the number of medical school graduates per 100k population than the US, and unsurprisingly compared to the US it's easier to get general medical and specialist attention.

Oh okay. Guess we’ll just continue to have 1997 level supply of doctors forever.

I don’t even know what argument you’re trying to make here? It’ll take time to solve? Yeah, obviously. That’s why we should start ASAP and given that we don’t have a time machine, that’d mean right now.

The supply of new doctors (and residents) should at least keep pace with population growth. For whatever reason, we spent nearly two decades keeping this number flat even as population grew by 70 million. We shouldn't have to double these numbers, they all should have organically increased at a reasonable pace. But for a variety of reasons they didn't and now we have to fix the problem.

Why do we blame this on medical lobbies when it appears to be the same issue across the board for funding state education departments?

Because it’s a different issue with different principals involved.

Does the federal government set the national number of teachers who can be trained each year?

I have no idea, but that’s not the point. The funding they put into each state’s education budget, combined with that state’s policy effectively limits hiring.

> They exert enough influence over all fifty states and the various private institutions to systemically deny training to qualified candidates?

Politicians "trust the experts" and the American Medical Association says...

The flaw is the AMA is just a union for doctors not a body that represents patients in any way.

The American Medical Association says ... we need more doctors and Congress should increase Medicare funding for residency programs.

https://savegme.org/

Which is pointless without also increasing the number of medical student slots.

The AMA doesn't control the number of medical student slots either. They have no regulatory or accreditation authority. Medical schools are free to add more students, and several entire new medical schools have opened in the past few years.

https://www.deborahgutmanmd.com/blog/new-medical-schools-upd...

The immediate bottleneck really is in residency programs. Every year, some students graduate with an MD/DO degree but are unable to practice medicine because they don't get matched to a residency program.

In the late 1990s, the AMA lobbied to reduce available residency positions and residency funding.

https://blog.petrieflom.law.harvard.edu/2022/03/15/ama-scope...

Exactly: I want to see more/newer data on residency programs and placement rates per resident (MD, DO, IMG), because last I checked, residency spots (and the bottleneck created by limited Medicare funding, which I find interesting considering the profit created by residents) were the primary bottleneck; medical schools have every incentive to open new spots as quickly as humanly possible considering the ludicrous pricing they charge. We're firmly into 'money printer' territory for medical schools and their cost of operation.

AMA is not a union, it's an association, akin to the National Association of Realtors, or even the "National Association of Photoshop Professionals." There are big differences between a professional association and a union. For starters, a Union would likely demand required overtime pay for the on-call shift, a cap of max hours worked, likely plenty more. I'm not in a position to judge whether those kinds of demands would be a positive or a negative, but it's a big example of a difference between a union and a professional association.

> The flaw is the AMA is just a union for doctors not a body that represents patients in any way.

Ergo, AMA is not a union, hence that cannot be a flaw in the AMA. Chastising the AMA for not representing patients because it is too busy being a doctors union is a straw-man argument.

One thing that a generic union has in common with the AMA specifically is that both only care about its members, not anyone else, and will vehemently argue in favor of things that enrich its members at the direct expense of everyone else.

The overlap of commonality does not mean a lot, a professional association is not a union, a union is not a professional association.

I think there is unstated subtext perhaps in your criticism. To one extent, a unions job is to care about its members. It is _not_ the unions job to care about anyone else. If the union acts in the interest of anyone other than its members, it is not doing its job. I think that criticism is more of a definition almost. The seamstress union was not created to care about the CEO and managers, but seamstresses.

It's hard to say a bit whether union benefits always do come at everyone else's expense. I'm reminded of the argument against $15 minimum wage. According to one third of business owners in 2021, it was going to cause layoffs. [1] That did not happen in Seattle where that was tried, instead the data shows: “Seattle’s minimum wage ordinance appears to have delivered higher pay to experienced workers at the cost of reduced opportunity for the inexperienced,” [2] Despite the data, there is still the claim that mass layoffs would be necessary.

I think this perhaps dovetails into the debates of trickle-down (AKA supply side economics) vs bottom-up economics. Be what it may, not everything union is good, yet you can still thank them anytime you have a weekend. [3][4][5] I'm just saying, be cautious when painting with a broad brush. The idea a union helping its members will always be at everyone else's expense strikes me as an anti-union talking point rather than something grounded in firm data. Could be true, but without citation showing that to actually be extensively true, I do not take that statement at face value.

To be sure, the _only_ claim I'm making here is that a union and professional union are not the same thing. I'm super skeptical of all these other claims/statements being made and am not really willing to accept anything on face value here without evidence, particularly broad generalizations. The points I raise I think bring some refutation to those generalization, which does not mean the inverse is true, but simply that those generalizations are neither helpful nor informative.

[1] https://www.cnbc.com/2021/02/10/one-third-of-small-businesse...

[2] https://fox59.com/news/heres-what-happened-when-seattle-rais...

[3] https://www.politifact.com/factchecks/2015/sep/09/viral-imag...

[4] https://www.unionplus.org/blog/union-made/eight-reasons-than... (this source is very biased)

[5] https://www.pbs.org/livelyhood/workday/weekend/8hourday.html

edit fixed citation links, one was missing. Added more citations in support of claim that unions are to thank for the weekend (please correct my history if wrong, my point is that historically, in the concrete, unions have done some really good things [assuming you believe not working an average of 102 hours per week is a good thing as was the case for building tradesman in 1890 [5])

> I think you’re giving way too much credit to medical associations to rig the game in their favor. They exert enough influence over all fifty states and the various private institutions to systemically deny training to qualified candidates?

The underlying fact that the AMA is directly responsible for the doctor shortage in the USA is historically accurate. 20 years ago the AMA believes we were heading towards a doctor surplus and heavily lobbied and for fewer medical schools, caps on federal funding for residencies and big cuts to the available residencies.

The AMA has reversed course and no longer supports these positions but the damage has been done, both to our supply of doctors and to their own reputation. However, even today the AMA supports many policies that keep taks that other professionals could perform the sole purview of doctors (which excacerbates the suppoy problem they helped create.)

I am wildly in favor of expanding the number of medical schools, expanding med school class sizes, expanding residency slots and funding per resident. None of this means I want decisions now made by someone who does 4 years of college, 4 years of med school, 3-7 years of residency and potentially fellowship on top of that to instead be made by a nurse "under the supervision" of a doctor. If you're a doctor of one specialty and you want to change specialties, you have to redo residency and maybe fellowship. If you're a nurse and you want to change specialties the training is either on-the-job or measured in days/weeks.

> one of this means I want decisions now made by someone who does 4 years of college, 4 years of med school, 3-7 years of residency and potentially fellowship on top of that to instead be made by a nurse "under the supervision" of a doctor.

That is indeed the AMA the talking point to justify their stance. However my problem with the AMA here isn't that they support some scope restrictions (clearly many decisions do require full training) but that they strongly support ALL scope restrictions without data to support such a rigid hardline stance. They do this even when the loosening scope restrictions would decrease cost and increase availability without any harm to patient outcomes. This absolutely exacerbates the physician supply problem that the AMA created. If the AMA actually care about the physician supply issues in the country, it would work with state and federal regulators to identify which scope restrictions can safely be loosened.

That it may be an AMA talking point doesn't make it wrong, and as far as I am aware the AMA is in favor of increasing physician at supply at the supply point - increasing medical school class sizes, increasing the number of medical schools, and increasing federal funding for residency programs (which can increase the number of slots, pay existing residents more, or both).

The answer to a physician supply problem is increasing the supply of physicians, not having nurses do physicians' jobs.

> That it may be an AMA talking point doesn't make it wrong

When an organization with a clear history of a specific agenda has a talking point, it is good to take the context of their agenda into account. I would point out that this particular agenda is one that has been largely achieved, which is why doctors in the USA make so much more than any other country and part of why our healthcare costs are so much higher.

In this case, we have a problem that the AMA deliberately worked to create for 20 years. Now that their "oversupply of doctors" myth is no longer remotely tenable, the AMA argues that the ONLY way to solve the supply problem they created is a solution that takes 10+ years to take effect.

We absolutely need to increase the number of doctors we have, but we also need to look at other ways we can safely increase patient access and decrease patient costs while we wait for new doctors to be trained.

The problem with increasing the supply of physicians it takes 10+ years for policy changes to have effects.

> They exert enough influence over all fifty states and the various private institutions to systemically deny training to qualified candidates?

Yes. What’s difficult to believe about this? People respond to incentives. The incentive for every physician is to maintain a shortage of physicians, therefore improving the job security and earning potential of every physician. The only way this could be done is if the physicians formed some sort of cartel that could control how many people were allowed to become physicians. This is what the AMA is and what it verifiably does.

This is definitely the case in Finland too. Somehow there's a chronic shortage of doctors, but only minimum increase in number of students, something which government could easily control through funding. Meanwhile lots of other university degrees have become less and less valuable, because too many students graduate.

Doctors's simply have the strongest association/union to preserve their privilege. No wonder why they easily earn way more than your average senior software engineer, lawyer or whatever around here. After the first few years from graduation, many of them go work in private sector where there's generally less stress, and 3-4 day workweeks are pretty common too, as they can afford it. Not a bad deal at all.

Here it has got to the point where young Finns pay money to go study in poorer countries like Latvia and Romania, because it's too hard to get in medical school here.

Because you can't just set a higher number of students per year, for more students you have to create more facilities first. It's not like IT, where you can learn everything pretty well basically just with a study program, books and online lectures. As a medical student you have to do a lot of practical stuff with things that you don't get at home.

Facilities can be built. Training programs can be expanded. Those are reasons why programs can't be doubled this year, but inside of a few years it's all possible. This problem has been cooking for decades.

What actually happened was cartel shit.

https://www.washingtonpost.com/archive/politics/1997/03/09/r...

I agree with this - in the US we have nurses picking up doctor roles (e.g. anesthesia), hours-worked caps, PAs (physician assistants) also picking up doctor roles, tons of international physicians coming for underserved specialities (family medicine, pediatrics, psych, etc).

And of course, residents super overworked. I think it speaks for itself that making medicine 2x - 3x more people per year would help the problem. Yes, there's a "sweet spot" where quality of doctors would drop, but there's also a sweet spot where services rendered drop due to overwork, and we're on the far side of that one

Yep, and it'll get worse before it gets better. The boomer wave will (continue to) hit faster than we can grow the system. The best time to fix it was a decade ago when everyone saw it coming, but the second best time is now.

“…doctor roles (e.g. anesthesia)…” Anesthesia has primarily been a nursing role, and it’s been this way since the American civil war. Physicians didn’t really want any part of it early on as it wasn’t very prestigious or lucrative. Nurse anesthetists have historically provided and continue to provide the vast majority of anesthetics, in the US at least.

it's a monopoly end of story

in portugal, public workers are one of the biggest lobbies

medicine

- can't be taught at (non public) private universities

- there's limited growth in class sizes/etc

- it's nearly impossible to get into due to grade inflation at high school, which means only the richer paying for private high school pass it (requires grade 19.x/20 at least)

At the same time, there's 100s of nursing schools (can't be too different can it?), there's way too many nurses and way too few doctors.

We're importing doctors from cuba and other countries to fill the gap.

Some people decide to study abroad (within EU) because yay, you study medicine in eastern europe, you may come back to work in Portugal because EU, and again only the richer people could afford this

In the UK, many highly rated Universities would love to be allowed to take more medical students, and expand their facilities.

That would be the university's decision, then, not a state-mandated cap.

I have asked my doctor friend about this and it's because university courses are tied to actual hospital placements and training, there's really a limited amount of students that can properly train to be doctors because they do half of it on a ward. That's the reason there's such an expansion now of Physicians Assistants, which are like doctors but missing half the training.

I can't find anything to support this online, but I do distinctly remember reading once that the cap on medical student places goes back to the founding of the NHS and negotiations between the government and the BMA. (One of the issues at the time was persuading doctors to join the plan, and they were afraid of a drop in income).

It's fairly trivial to analyse population vs. medical student places and see where the problem lies - there was an expansion in training places a few years ago, but it's a pipeline problem, and doesn't get fixed overnight. If somebody really wanted to fix things, there would probably need to be some kind of accelerated training of doctors and nurses for a few years.

In France, like in others countries, we have the same kind of problem. So much actually that we "import" medics from other countries !!!!

Lastly, the gov finally acknowledged the problem and tried to suppress the "numerus closus" (limiting the number of medecine students) but the problem is now that... there's

- not enough teachers and not enough room in universities

- not enough position in hospital for "internship" (not sure if it's the right word) because theses interns have to be managed by experienced medics

- it takes a loooooong time to make a doctor

- "young" doctors don't want to spend countless hours without personal life like previous generation did... so more doctors are needed !

And the problem is even more pregnant for out-of-hospital doctors (particularily outside of cities)

Right now, the gov strategy is to try to give more and more power for nurses, pharmacists to limit load on doctors (and cost for social services)... but sometimes doctors may spot specific symptoms where others may not

Supply management. It’s how you keep incomes artificially high.

> Something I've never quite understood is why, in the UK, we cap the number of medical students per year.

To keep salaries high.

I'm brazilian. In recent years, brazilian medical schools have been "democratized", so to speak. The number of medical schools has exploded and acceptance of doctors from neighboring south american countries has been facilitated. About 50 thousand new doctors enter the market every year.

Result? Pathetic salaries. Actual unemployment. Doctors fighting each other over the shittiest jobs with the worst working conditions. Doctors becoming Uber drivers. Complete loss of the prestige the profession once enjoyed. Rampant charlatanism and unethical conduct. Badly educated doctors who kill their patients. Dishonest doctors promising miracle cures on Instagram because that's what gets them engagement and therefore patients.

There is no reason whatsoever to become a doctor under these conditions. Too much responsibility, too little reward. You're better off doing literally anything else.

Society needs to carefully consider the needs of those who will be responsible for other people's lives. When responsibility does not equal reward, it's pointless. My society chose to treat those people with absolute contempt. The results are plain to see.

Thanks for contributing that point. It’s good to have one data point for what happens when there are no restrictions.

I’m from Ireland and have the same experience as most of the rest of the commentators on this thread, i.e., we have a chronic shortage of doctors – and nurses – in our health system. This has been the case for as long as I’ve been alive but it’s got much worse in the last decade or so.

It’s interesting to see how universal this problem is – aside from the odd country like Brazil where the pendulum seems to have swung too far in the opposite direction. It’d be nice to know if any country has found a happy medium.

> we have a chronic shortage of doctors – and nurses – in our health system

Just imagine how bad it's going to be once the "you're set for life if you go to medical school" meme dies. It's still very much alive here in Brazil but people are already being forcibly woken up to face reality before they've even graduated. Won't be long before the new generation of students realizes that medical school is a bad choice.

The bitter truth is nobody is really going to put the "care" in health care if they're not getting paid ridiculous sums of money for it. Would you really want to slave your life away in some hospital for shitty pay? I mean that literally, medical residency is analogous to indentured servitude. Would you want to spend the best decade of your youth studying and training and working 14 hours a day only to end up poor? I've seen doctors actually kill themselves over lesser failures than that.

Very few people are that selfless and altruistic, even those who affect such a demeanor in public are likely secretly hoping it will come back to them in some way in the future. They will be bitterly disappointed when it doesn't. Even fewer are rich enough that they can sustain such caring activities out of love. Those who try discover that they are just individuals, that they don't scale, they don't form a health care system. They don't make much difference in the grand scheme of things.

Today I saw an interesting post from an older doctor. He just straight up quit medicine. Took his money, bought a bunch of trucks and now he's managing a logistics company and making several times as much money as he used to while caring for people. This is an older doctor who reaped the profits of the golden age, he had the capital to create his business. New doctors arrive at the market with 100kUSD+ debt only to find that they get paid about 10 dollars a consult if they're lucky. The only winners here are the owners of the medical schools.

This just goes to show yet again that healthcare and markets are largely incompatible if you want to have good outcomes and ethical treatment of people.

When I was studying in the US, my roommate was studying to become a "physician assistant" — a concept I think is brilliant. I don't think there's anything similar in my own country.

But I was wondering if more physician assistants would help the doctors. Maybe they could take care of the paperwork and all those things as well.

A brain surgeon saved my sister's life. In the days after her recovery, my dad ran into her surgeon eating in the hospital cafeteria at 11pm. My dad asked him when his shift ended and the surgeon just looked at him and said, "I live at the hospital." There was just so much work he had to do. Rewarding work, but grueling.

That was very funny - I laughed out loud :D

I don't understand why doctors that are entering the field need to be over-staffed and over-worked. I have a cousin who is an Er surgeon and she needs works 3 days a week, but that certainly was not the case when she was starting out.

The work culture of the medical profession looks horribly inefficient. What benefit do you get from buying out young doctors?

Discipline. (I am not saying it's worth it. I don't know.)

Poor incentives for the existing members of the system that hold power to implement change. They already cap the number of med students to control salaries, perhaps burning out young doctors fulfills the same purpose, while also (temporarily) covering for the lack of doctors available because of the artificial limit?

Some wards with really sick people benefit from having longer shifts as you see the person progress and have fewer shift changes. Ie with 2 people doing 12 hr shifts is better than 3 people doing 8 hours shifts as the doctors and nurses see how a patient is doing and dont have to communicate to next shift. Something like ER where people come and go all day wouldn't benefit from this however.

Yes but you really don't want to be treated at the end of that 12-hour shift, quality of service drops down significantly, they are significantly more tired at that point. Doctors are just humans like rest of us, and those shifts are often brutal.

That’s what I am trying to say, sleep deprivation causes people to make mistakes.

I’d rather have three well-rested people and an additional shift change than two burned out, exhausted people. People who are exhausted make mistakes. Maybe it would be better to focus on improving internal communication.

Maybe, I think we have to trust the medical people that they know what they're doing. My baby daughter was in incubated in ICU twice with severe Bronchiolitis. It was nice to see the same people look after her for a week rather than a continual stream of people clocking on and off.

> It was nice to see the same people look after her for a week rather than a continual stream of people clocking on and off.

Surely those people were sleeping from time to time during the week, weren't they? That is the "people clocking on and off".

Have you looked at the research regarding which of those two options leads to better patient outcomes?

Have you? I’d love to hear that answer.

I have. Longer shifts with fewer turn-overs results in better patient outcomes.

And that makes sense, but only if there are enough breaks and downtime in between, and probably not if the doctors hasten from one patient to the other.

Could you link the studies?

That's strange as you would expect quality to suffer in every single respect when forced to work inhumane conditions. I would find a different mechanic if I thought the one I was considering was miserable from being overworked. Was there an explanation for why outcomes improved? Perhaps it is necessary to look into who conducts these studies as I imagine someone up the ladder profits greatly from having 1 doctor do the job of 2.

One simple reason might be this over: people make errors over time, but they become familiar with the case. That familiarity is lost whenever they hand over a patient. And you can't solve that with documentation since people would be busy all day doing paperwork instead of caring for patients.

This problem exist in every domain, and in medicine it can have deadly consequences. People sign up to become doctors knowing that they will have to work crazy shifts. But I guess they underestimate how the system hobbles them since it is focused on being efficient, not on achieving the best outcome for the patients.

Quality does suffer as the hours drag on, but quality suffers more when you hand off a case (which can be quite complex) to someone else. The tired but experienced-with-this-case doctor still does a better job than the rested doctor who is brand new to the patient's case.

Source?

That answers the wrong question.

I would agree, assuming the patient workload is appropriate, I think it all depends on how busy the place is. I've chosen to do 24 hour ER shifts instead of 2 12-hour shifts in a place that would see about 1-1.25 patients per hour, mostly during the day so I would usually get 2-6 hours sleep overnight. But in a busier place, I would much rather work a 12, 10 or 8 hour shift as the intensity increases, say to 2-3 patients per hour. And the case mix also matters a lot, if you have a bunch of patients with coughs and colds, or minor injuries, you can see 4 an hour easily, if everyone is a demented nursing home patient or requires a translator, seeing 2 / hour might be crazy hard.

Source?

Just from looking at the massive amount research on the effects of sleep deprivation and burnout on humans, and assuming that medical professionals are humans, we can infer that performance would decline. But ok, I’ll play along.

https://bmjopen.bmj.com/content/9/1/e024778

https://www.healthecareers.com/nurse-resources/nursing-patie...

https://journals.plos.org/plosone/article/comments?id=10.137...

It’s a mixed bag, but strongly leaning against longer shifts, in my opinion.

So would I.

Rounding is a major source of mistakes. It is very common that cases rounded through multiple people develop major gaps in information. This is not as simple of a problem as you think it is.

I feel like technology could very easily solve this eventually

Only if you think it's possible to get all of the information in someone's head out of their head without consuming significantly more of their time and energy.

Quite possibly one of the worst instances of “let me solve this problem with some code” I’ve heard.

If you find some problem that plagues millions of very smart people, and your thought is "technology could very easily solve this", the first thing you should ask yourself is what you're missing.

The problems are aversion to technology in places, unwillingness to adopt new (human) protocol/processes, entrenched proprietary technology, that does not adhere to standardized formats.

Say you want to save a report for a patient for the next shift. That report needs to enter a computer system. If there is a system for that, it will most likely be a very expensive overpriced proprietary solution with expensive support contract, instead of something that has an open and intelligent format, that could be read by simply any software. The companies behind the tools will paint themselves as "specialists" for medical technology and do everything to dig a moat, at the cost of lives and they will avoid standards, as that will make their overpriced solution replaceable.

https://xkcd.com/1831/

I have to disagree on the "aversion to technology" point. It's something I've heard ever since I started working in software development, this isn't isolated to healthcare.

For sure, there is always some resistance to the extra work of learning something new. In my experience over many years, it's easy to overcome this resistance by showing clear improvement achieved by the new process, whatever it might be (change in order of process steps, new paper from, new software, etc.)

After working in healthcare (mid sized hospital), there is a big problem with pressure from administration that often makes little to no sense to those whose work is changing. I think a lot of this comes from weird incentives that maybe make sense in terms of short term business gain but, perhaps, are not worth the disruption to so many people's day-to-day work.

Lastly, in the field of enterprise software and healthcare in particular, I agree that many of the technical solutions are not great. There's a lot of resistance to changing software tools simply because people have changed so often and the tools are so poor. Often these tools do not come close to the promised improvement.

> The problems are aversion to technology in places, unwillingness to adopt new (human) protocol/processes, entrenched proprietary technology, that does not adhere to standardized formats.

It is not. This is a classic example of assuming the problem exists within the realm of your current understanding.

The stereotype of people in medical roles not wanting/liking/understanding technology is wrong. What we don't like is the god awful technology we are handed because the work hasn't been done to understand how we work. THAT technology is not worth learning or caring about.

As someone who has rounded patients over many times, the problem is the extensive amount of information that is ingested into establishing a cohesive clinical picture of a patient, then continually adjusting the degree of confidence in numerous facets and levels of the case. Then it all gets dumped into the heads of the next group of people.

So people in tech develop these programs to help track the information. Yet they fail to grasp that there are many situations where the conclusions are based on a web of contingencies that operate on disparate time series, are affected by a wide net of things not directly reflected in empirical data, and it is completely impractical for me to continuously update the intermediate changes to my conclusions just so your software can know what's going on. The more that people try to construct a UI that captures the complexity of what can be noted in a case, the less usable it becomes. Even then, they still undershoot the level of depth needed to reflect what doctors are tracking in their heads. You may think it's enough to have someone input the hematologic data as the results and their ranges. You fail to track that my interpretation of those results is contextualized by the fact that nurse Martha was on the floor and likely dropped the ball on how promptly the ABG was run, and that certain staffing dynamics affected how much weight I give certain subjective criteria. In rounds, a simple eyebrow raise can be enough to convey to the next shift a mutually known dynamic that affects how information should be interpreted. Asking us to spell all of that out in your "new technology solution" won't happen. It is a waste of everyone's time and social dynamics will prohibit it.

I could go on and on with a variety of other examples, but I don't have the time or desire to do so. My point is that the tech hubris is wasted effort. While you sit there thinking you need to teach the "tech illiterate doctors" how to follow matters of process, we see you as someone that has been asked to develop a more effective tool, and you hand us a fisher-price screwdriver and insult us for not finding it useful.

Like the other comment said, https://xkcd.com/1831/

I happen to know someone who works in a hospital, in a lab, looking at blood samples. The stories I often have to hear about how little technical knowledge people working in the hospital have, or at least apply to what they are doing on their job are ... not very encouraging, to say the least. So I am not actually as clueless about how hospitals run, as you might assume.

It is not all doctors, but also other personell at hospitals. But also doctors. Some are known to take too little blood from patients to run proper tests. Or too little urine. Or use the wrong containers for the samples. All very avoidable, if people did not refuse to learn abour their own job's processes. People can be, and are often very learning resistant, especially non-technical people, when it comes to learning technical processes, new software, or new workflow processes.

What is more is, that hospitals run on lots and lots of proprietary machines. But they do not always run them correctly. No, even when being told, that the machine must not be in a room warmer than X degree Celsius, they run them above that temperature anyway. Sometimes without better option, because they do not have the appropriate rooms for running them according to how they should be run. Don't get me started on proprietary protocols and file formats, probably wheel-reinvented by an intern or an evil genius, who was told to make interoperability with machines and programs of any other manufacturer impossible.

Yes, you may be a well-oiled team running the place at work, but some of what you write makes me think, that you are part of the problem, refusing to put things into written form. In software engineering many (but not enough yet) have long learned, that what you do not document properly will eventually get lost and might need to be rediscovered. If you cannot write down your thoughts regarding a patient, what happens, if the next day you have an accident and cannot tell anyone your custom interpretation of measurements? What if your coworker or fellow doctor, who understands all your subtle signaling like some raised eyebrow, cannot make it to work tomorrow? And do you really want to handle patients based on whether your coworkers eyebrows behaved, when you were talking to them on shift change/handover? I hope not.

Basically what you describe sounds like a very person dependend process and leaves lots of room for mistakes, when things are not explicitly spoken or written. It may be, that inputting everything into some IT system takes a lot of time. Maybe you need better methods of inputting things. It is a valid concern. But your kind of attitude "tech will never be able to capture our work" is not helping anyone. A good solution will naturally involve countless hours of observation of processes in the hospital. That is what business process modelling is all about. Of course the process needs to be captured and analyzed. That however, is a 2-way street:

Sharing all the little signals and what they mean with some observer of processes is essential. They needed you to tell them these things. If you think the tool is "fisher-price", then why haven't you told the people, who came up with the solution? Did you sit there silently, saying nothing? If so, then who is wasting other people's time? Or did no one actually observe the processes and came asking about your work and how you do things? If so, then that is a really bad process of trying to improve things and I am sorry you were treated badly and not not surprised by the result.

Who thinks that they can solve all the problems without observation will fail, especially in a hospital. But that is not the matter I was getting at. I don't know where you are a doctor or so, but at least from the stories I get to hear from the hospital, I know that hospital staff has lots to learn in terms of following processes and saving time by knowing a little bit about the work of other departments, like the lab.

Imagine telling a doctor how to be a doctor because they "happen to know someone who works in a hospital". Oh how I would love to have you shadow me on the floor for a week.

> If you think the tool is "fisher-price", then why haven't you told the people, who came up with the solution?

Because they react just like you did.

You perfectly demonstrated why I moved over to the software side. The doctors I work with are sick of the hubris from people who don't understand medicine, so we decided that it will take doctors who are willing to learn software development to actually solve our problems. It turns out it's much easier for doctors to learn how to develop software than it is to teach devs how to be doctors.

Now you make yourself look like a bitter person, since according to you all the software developers in the world will react a certain way and nothing can be done, except you, the holy doctors, showing the devs how to do their job, by becoming developers yourselves!

Meanwhile talking about hubris ...

All the while you could not be bothered to document things and not telling someone who tries to help, where their solution falls down, so that maybe they could improve, but at the same time keeping complaining about "fisher-price". No way they could have any new ideas. You did not have them, so how could they ever have a good idea for improving status quo. How I would have just loved to onboard you onto my engineering team! I am sure you would be great to work with, since sharing information seems to be your strong suit.

It seems very clear to me now, that you did not want things to change as a doctor. Did not want improvement, since nothing these engineer plebs could do would be good enough anyway. And that kind of attitude is exactly what made you part of the problem.

It is clear that what what I just said is being distorted for preserving ego. That does not lead to productive conversation. If this is an active area of interest of yours I would advise you to listen to subject matter experts instead of attempting to lecture them.

If you don't mind me asking: Do you see a solution, technical or otherwise, to this problem?

My guess is there are limits to knowledge transfer that's difficult, if not impossible, to overcome.

You are correct that the problem is an information bandwidth issue.

The number of variables that must be considered for any given case are extensive and multi-layered. I don't have the time to get much in depth on this but off the top of my head: - There can be errors in our lab tests - The errors are test-dependent in degree and significance - Less than ideal handling or sampling affects different analytes differently - Errors in one analyte can affect others - The absence of deviations from normal in some tests can itself be an abnormal finding - Sometimes abnormal findings can be due to error or genuine in an unknowable way - The confidence of what constitutes "normal limits" is dependent on the underlying epidemiology of what is being tested for - There is no realistic way to have a unified data model for everything we assess - Much of what is interpeted/assessed gets reported as paragraphs of text - Missing data can either be untested or unavailable and it is not always clear which it is - What is communicated to you may be dishonest (such as drug seeking behavior) - As much as we have tried to standardize fundamentally subjective assessments (such as murmurs) they are still subjective - The MO is to push providers to the limit of what is safe in terms of number of cases and aggregate complexity - Putting humans in the loop of anything opens up to emotional/social factors that can influence interpretations/trust in various factors

I could go on, but the point is that as a result of all of this, the most efficient route by far is passing information directly from one caregiver to the next since they are often operating on a platform of context (much from their training) that is difficult to replicate in software.

The solution in my mind is lifting providers off of the low level data and activities. If we can close the loops on automating decisions in a generally agreed upon and reliable manner, it removes the need to discuss or think on the information fed into that system. Clearly that is a big task, but the realistic path forward in my mind. Harping on matters of process at the same level of detail is a waste of time and effort.

But why not 3x12hr shifts rather than (what appears to be from outside perspective), 7x12hr shifts?

In reality it would probably be 2 people doing 13h shifts or 3 people doing 9h shifts, in order to have overlap for handovers and because of hygiene rules, that do not let you walk right in.

Personal suspicion is a big part of it is just the people with power generally being fairly old, and not particularly caring about young adults generally.

They make the hospitals follow plenty of rules, but let them ignore labor laws in this case.

One thing is that the rigid terrific schedule of the modern-day residency program was designed by a cocaine addict who made the structure to fuel and hide his addiction, so all doctors start out with a skewed sense of normal working hours. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7828946/)

Another thing is the toxic culture perpetuated for allowing medicos to stroke their egos - toxic cultures about overtime are everywhere, but medical profession is a class apart.

I remember hearing this story on the Joe Rogan podcast. I was so astonished, I could not believe it until I looked it up myself.

Further worthy to note the culture inside surgery departments and residency programs, which seems to feed on exactly this sort of toxicity to measure the worthiness of applicants / residents / graduates. Young surgeon hopefuls should seriously consider the residency process before committing to the field; one of my wife's former co-residents, now early in surgery residency, is surprised by her own fertility challenges, for example. Anyone 'in the business' knows cases like this, and it's a good thing that suicides are national conversation.

My not so generous and extreme take is that the medical profession has a “hero culture”.

There is prestige in working your ass of and living for work. Work life balance is for the weak people who can’t take it, they are not real health professionals. They don’t have what it takes.

I have seen the same culture in aid work.

I find it ironic that both health professionals and aid workers are there to help people, but not for each other. Then it’s cut throat.

Yes this does seem to be the culture, at least for doctors working towards the more competitive specialties (such as surgeons). Things get much less hectic once they reach “consultant” at age 35 or so, but it’s an absolute grind until then. With no guarantee of success! If you see your GP with a bunch of extra paper on the wall, chances are they are one of the many that didn’t win the game.

What’s a good alternative though? These are high paid, high status, jobs for life. Of course it’s going to be as competitive as all heck to get them. Do we shame Olympic athletes for the dedication and sacrifice they must provide to obtain their goals? I’m not saying the current system is great, but any alternative could well be worse.

“Jobs for life” part is huge and under appreciated - there aren’t many jobs where you don’t have to worry about ageism nowadays

Health care professionals do form unions and go on strike sometimes, which can be seen as a way of looking out for each other.

Having friends on the other side of those medical union strikes, I think the hospital systems play hard ball and the unions don't get good outcomes often. My friend quit the hospital because how they were wringing her dry and pushing economical things that she found unethical. She quit and started her own private practice, makes more money, works less hours and is much happier now.

Hospitals also have non-competes, so doing a private practice isn’t that straightforward.

But I wish we had more private practices where doctors had more control and optimized for patient well being.

One of my friends I grew up with was “that kid;” smartest in the community, funny, played a mean guitar. Everyone loved him. Top of class. Harvard. Harvard med. Top placement for residency. Something happened during that time and he killed himself. It was absolutely unexpected from all of his friends. Shocking to say the least. Apparently it turned out to be stress from work, his hours, his fear of failing. Who will ever know, but it has been many years and it still stings.

Can't medical doctors have duty time limits like aircrews. Wouldn't that alleviate some of the overwork.

it's not like the whole profession has the same contract, but working hours in public healthcare should be regulated, i agree

Can’t IT workers?

There is such a restriction, at least for NY. It was prompted by a wealthy businessman (naturally): https://en.wikipedia.org/wiki/Libby_Zion_Law

Last I heard (this was early 2010s) at least it Texas, it was capped at 80 hours/week for residents. Seems like a lot but probably better than the 100+ they used to pull.

80 hours a week, averaged over a month. So individual weeks can still easily go over to 100+

My wife's a doc, in residency, and also Swiss, so I find myself referencing this study [1] on residency hours in Swiss residency programs over years. Bottom line: there are limitations on hours/wk and consecutive shifts, but enforcement of that is a joke + nonexistant, especially among residents (note resident's interest in maintaining their resident status and remaining 'bureaucratically blessed'). [2] See the Albuquerque neurosurgery resident walkout for an interesting business case of the real value of surgeon residents and what might motivate them to cause a big kerfuffle in hopes of bringing about changes. [3] I'm mostly acquainted with attending physicians who don't mind the 60hr weeks when they don't have a choice, and residents who pick up the rest of the work that attendings financially benefit from. Surgery attendings seem to be a special sort of animal. It's just not as simple as limiting hours, unfortunately -_-

[1]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3464122/ [2]: https://psnet.ahrq.gov/issue/public-opinion-resident-physici... [3]: https://thesheriffofsodium.com/2022/02/04/how-much-are-resid...

In the US, there is a cap for residents: 80hrs per week, but averaged over a 4 week period so individual weeks can go over

It's not the pressure or hard work that breaks us, it's the frustration from not being able to control anything. It's the knowledge of knowing that if you had some amount of say in what was going on, things could improve for everyone. And knowing that people who are not impacted by this in the least have all of the power. So you can either quit what you love, or keep doing what you love in a psychologically unsafe, unhealthy, and toxic system.

> Apparently it turned out to be stress from work, his hours, his fear of failing. Who will ever know

You are saying that 'it turned out to be stress from work, his hours, his fear of failing' but then 'who will ever know'.

Also why does it matter that he was such an apparent (to stress) academic high achiever? That doesn't make you immune in any way to anxiety or making other life choices that could be detrimental to your health. Understand that you are adding color to your story but really the 'loved, funny, played a mean guitar' why does that matter?

Easy answer appears to be he was pushed by others (or himself) and went into a field that he was not (mentally) able to do. After all most Physicians are not killing themselves (high achievers who go to Harvard or a less impressive school). Literally the same thing could have happened to him if he went into any number of high pressure fields or had other mental issues.

> I went into medicine knowing that I will have to sacrifice much for the sake of my patients. What I am realising is that today in modern medicine, a doctor is just one of the many commodities in this complex industry. It’s no longer about the patient. It’s about the business of hospitals. Patient satisfaction officers, Theatre Utilisation officers, Patient Flow Coordinators. These are all business roles.

I have to yet to meet one person who says American Healthcare is wonderful, fairly priced and efficient.

It seems private Equity and mergers are slowly juicing out the system - the doctors, patients, nurses.

Its a sad state of world that we don’t allow pilots to overwork because our lives depend on it, but we allow doctors to overwork and don’t count patients dying due to them being overworked.

Re pilots vs doctors: pilots would be the equivalent of elective surgery, i.e., it can wait.

There are so few doctors that getting a tired doctor is "better than nothing" as you have a greater chance of survival if you get mediocre care vs no care at all and certain death.

Ironically, the reason my wife, a physician, gets to see her dad, a private pilot, most often is when he's flying medical teams to harvest organs from organ donors. 'Agreed' to your points, at least in part ;)

Right. And we have so few doctors because we artificially cap the number of doctors instead of letting free market dictate how many doctors we can have.

You remind me of an old article I read:

https://philip.greenspun.com/flying/unions-and-airlines

probably not a 1:1 comparison to health care, but the conclusion was:

> a sustainable long-term structure would be a pilot-owned airline

I kind of wonder if there could be a way for doctors to start a hospital and run it top-down from first principles.

Kind of like good engineering companies that were started and run by engineers.

Most of the issues mentioned in the article and the included email are concerning, however they also oddly seem to be common in many places across the globe. The surgeon mentioned was in Australia, I have seen these issues first hand in the Netherlands and am aware of very similar of the first 2 out of 3 issues (caused by overwork/understaffing/over-fatigue etc) in Belgium, Germany, the UK, India and god knows how many other places.

However, fields like aviation have strict workload limits. You cannot be on call/duty for too long because fatigue kills. Issues like alarm fatigue are studied by agencies, and folks at Boeing/Airbus then implement the findings.

The question is, why is it okay for medical professionals to wear themselves down to the bone (sometimes literally, like in this article), while some other professions take care to avoid it?

(Edit/PS: I added a fairly detailed self-reply below on what I think are some of the common arguments (like on the number/availability of doctors) and why they don't really fly, pun not intended.)

(My musings/thinking-aloud): One partial hypothesis/answer is that there are far fewer pilots/cabin crew than there are doctors/medical staff, and hence it's easier to treat pilots properly. But fewer people makes it harder to let someone off if they haven't slept well so I don't really buy that.

Another is that the medical profession is much more "flexible"/fluid in its needs, unlike flights scheduled in a regular manner. However, that doesn't mean it's not possible to give doctors an 8 hour workday, and substitute/bring more doctors for other shifts. In fact, this is exactly what happens in many 24-hour manufacturing plants/operations. Foxconn doesn't let a sleep deprived employee make an iPhone, but it's okay to let a sleep deprived doctor perform life-saving/potentially deadly operations?

Another possibility is that "it would cost more" to have 3 docs instead of 1. Which might be supported by anecdotal evidence on how expensive things (including salaries) are in the medical field. However (especially if you're only familiar with the US healthcare system), this doesn't explain how doctors in say India are overworked.

The "real" reason, I think behind all this? The first part is it's because it's "easy" to compress and push an 8 hour shift to a 24 hour shift, fatigue be damned. The costs are "hidden", it's likely even with fatigue a 99% successful operation is still 95 or 90% successful. Everyone can rationalize it and go about with their day. "Oh, unfortunately people don't always make it".

Not, "there was a 20% chance they wouldn't have made it but an 80% chance it was because the doctor was fatigued."

When an aircraft crashes, 300 people may die instantly. This gets front page coverage on a newspaper. However, a few deaths "here" and "there" don't really show up, even if they tally up to thousands. This is the second factor, that "hides" and normalizes occasional slip-ups.

</End of this wall of text> I unfortunately don't really have a solution. I'm sure there are brilliant UX designers here on HN who could help ease and streamline the admin workload.

I suppose a dedicated politician/presidential candidate somewhere could take this upon themselves to campaign for. (Seriously, the NHS was part of the discussion behind Brexit. Supporting doctors is a brilliant political strategy, the NWA didn't have a song called "Fuck the paramedics".)

There have been many instances of things catching on once found successful somewhere, be it procedures like the Heimlich or concepts like Lean Manufacturing. Therefore I don't doubt that one good Harvard Review paper showing a 20% decrease in all-cause patient mortality, with trials underway in a few hospitals, is all it will take. Question is, who will bell the cat‽

Thanks for the perspective. I have doctor friends and everyone seems to just blindly accept that some jobs are not jobs, they are identities. You never pause being a doctor. But your comment shows that even in life-critical environments, we do have ways of organizing work so individuals can bear it. Fire brigades are another example.

Time to push for a change. And time to call some people and ask whether they are truly ok right now.

The understaffed healthcare system works with overworked doctors on the basis that having a tired and overworked doctor is a lot of the times better than having no doctor at all, because (s)he most likely can end up saving more lives than taking with their tired brain. If your operations have a 90% survivability rate it could still be considered a success despite those 10% they end up killing, because 90% is a lot better than 0%.

Meanwhile a tired pilot is more binary, it either can have 100% passenger survivability if things go well or 100% fatality if things go tits up, meaning the risk are too high to take chances.

It's basic game theory.

Good point, and you can turn it around: Doctors are never "finished". They could always do more to help patients. So in contrast to aviation, where there is a clear corridor of things to do, doctors have no natural upper bound on their work.

but the alternative isn't having no doctor at all, but to get more doctors, so the "basic game theory" is about why the limits on more doctors stay in place despite the higher risk of death etc.

> but to get more doctors

Have you found that magic fountain of endless doctors?

Sure, it's very easy! Just do things that prevent burnout (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8834764/) and the job gets more attractive, drawing more students and producing less attrition:

- Valuing work gives meaning (money, appreciation)

- Autonomy gives feeling of control

- Managing burden prevents overwork, exhaustion and fatigue

> Sure, it's very easy!

I have issues when someone says a complicated issue can be solved easily…realistic expectations…

The answers to some problems may be easy to know but difficult to implement, due to political/financial will etc. For eg we know how to reduce emissions, but it's still a challenge. In such cases advocacy and raising awareness can be helpful.

"Easy to describe" is very different from "easy to do".

It reminds me of the famous "just eat less and exercise more", the alleged simple solution to the global obesity epidemic.

Sounds good, but healthcare already constitutes 17% of US GDP. And with an aging population, spending has been growing faster than the rate of inflation. Most of the funding ultimately comes from governments, self-insured employers, and individual patients. Those groups have no appetite for spending more.

https://savegme.org/

The entire medicare residency slot system seems a bit self inflicted, why hasn't an alternative system popped up?

Also this is a global problem, not just the USA. You look at videos of student doctors in the UK for example and there are similar abusive schedules. https://www.youtube.com/watch?v=KE1XwEMGm0I

Read Adam Kay's "This is going to hurt" [1]. It was made into a miniseries. I read the book and it was so horrifying that I couldn't face watching the dramatisation.

It doesn't seem to be such a big problem here in Norway where things like working time directives are taken much more seriously.

[1] https://en.wikipedia.org/wiki/This_Is_Going_to_Hurt

Yeah it’s called correct incentives - I look at the over work, and insane stress levels that doctors suffer and I say “NO THANKS”

I am definitely not the only one

The AMA only allows a fixed number of seats in medical school.

There also can be tiers of medical doctors. Most doctoring work is routine, and can be handled by a more of a medical tech.

False. The AMA has no regulatory or accreditation authority over medical schools. Schools can admit as many students as they want.

The bottleneck right now in producing more US physicians is lack of Medicare funding for residency slots (graduate medical education). Every year some students graduate from accredited medical schools with an MD but are unable to practice because they don't get matched to a residency program. Congress hasn't significantly increased funding in years. At one point the AMA did lobby Congress to limit the number of slots but they have since reversed that stance and are now lobbying for higher residency funding.

https://savegme.org/

There are already tiers of clinicians. Much routine care can be delivered by Physician Assistants or Nurse Practitioners working under a Physician's supervision. Specific limits on their services are set at the state level.

Why do residency programs require subsidies, are resident doctors each a large net financial loss to a hospital? I can't think of many other career paths where someone out of school is so underprepared for the job that the business could not employ them without someone else footing the bill, doesn't seem like a reasonable system that will sustain itself in the long term. I suppose pilots are a bit like this but they typically take the financial risk on themselves to some degree or get the taxpayer funded training via the military.

Hospital accounting is always messy. There's no simple way to determine whether a particular program is profitable or not; it comes down to how the accountants allocate overhead costs. But the fact that publicly owned and non-profit teaching hospitals aren't voluntarily expanding their residency training programs is strong evidence that they operate at a loss.

Very few other career paths have such an extensive body of knowledge, licensing requirements, and low tolerance for errors. Law is maybe a bit similar in that new associates in most firms are worse than useless, and training them sucks up a lot of time from senior associates and partners. But law firms aren't subject to price fixing, so they have more freedom to raise their rates in order to cover those costs.

Do residency slots mandate public funding?

Aren't they doing actual useful work same as regular doctors? (albiet with a higher error rate)

So they could be funded through via charging for services rendered.

Of course their effective pay may be close to zero, after malpractice insurance, but it will still attract some number of med school grads who can't get in otherwise.

Residency slots don't mandate public funding. The majority of funding comes through the Medicare program but private foundations also contribute some. Private payers (insurance companies) also indirectly subsidize residency slots by paying teaching hospitals higher rates.

Some services performed by residents are billable, especially the more experienced ones. But the programs as a whole run at a loss after accounting for overhead so hospitals won't add more slots without a matching funding source.

Presumably it will only happen in hospitals that charge high enough rates to fully cover the cost of overhead, I.e at one of those luxury hospitals

What "luxury" hospitals? I've never seen the word "luxury" used to describe the teaching hospitals which train most residents. Most of them have high proportions of Medicare/Medicaid patients where rates are set by the government and hospitals have zero ability to charge more. I don't think you understand the reality of healthcare economics; this isn't a free market where sellers can change prices and supply to meet customer demand.

Colloquially, from the folks I've spoken to, luxury refer to those hospitals that offer high-end rooms, fancy furniture, concierge service, and so on, for a higher fee. I.e. Places where the differences are immediately obvious to the layman

If it's indeed the case that most hospitals can't cover their overhead then by default it must be limited to the high end, if it ever does happen.

> The bottleneck right now in producing more US physicians is lack of Medicare funding for residency slots... Congress hasn't significantly increased funding in years. Much routine care can be delivered by Physician Assistants or Nurse Practitioners working under a Physician's supervision

We should all accept a lower standard of care because hospitals can't find more funding to train doctors? What are all the $20 aspirin paying for? How does every other profession manage to train new members without needing a literal act of Congress?

Where would you suggest that teaching hospitals find more funding? Most of them are non-profits, or operate as part of state or local government agencies. They have no ability to negotiate higher rates with Medicare/Medicaid and only limited ability to negotiate higher rates with private payers (typically set as a multiplier to the Medicare rate). Voters generally haven't been willing to raise taxes. There is probably some waste that could be trimmed but it's tough to figure out where to cut without impacting patient care quality. Much of the administrative overhead is forced upon them by unfunded government mandates around reporting, quality, security, credentialing, and interoperability.

Private donors are always welcome. If you have a few million to spare then you can personally fund a residency program expansion at your favorite teaching hospital.

I won't attempt to defend ridiculous charges for certain basic medical services. Hospital accounting is a funny business, and almost entirely artificial. The teaching hospitals tend to deliver a lot of charity care (including writing off a lot of bad medical debt) and some Medicare/Medicaid reimbursements don't even cover their costs. So, they attempt to close the gaps by jacking up other prices as high as they can.

You should accept a lower standard of care because as a society we have limited resources and can't afford to waste them. If you have a boo boo then a NP can clean the wound and apply a bandage. That's what happened to me when I crashed my bike last year and it was fine. Physician time should be reserved for more complex cases.

Are you talking about the same hospitals that tripled the administrators to doctors ratio in the last 50 years (don’t remember exact numbers)? Is that why we need to accept a lower standard of care?

P.S. wait, you went to a hospital to apply a bandaid after you fell off your bike? Are you serious? Perhaps that’s the real problem…

The AMA doesn't have direct control over it, I was wrong about that. But they heavily influence it:

https://blog.petrieflom.law.harvard.edu/2022/03/15/ama-scope...

That's a straw man. We do not need "endless doctors" just more (or some way to use them more efficiently).

The number of doctors are limited by the pipeline to educate them.

Most countries I know, the number of people admitted to study medicine exceeds the number people wanting to study medicine vastly exceeds the positions to do so, and admissions are highly competitive. To a point, I'd say, that it is becoming ridiculous.

So, there is not a lack of people wanting to become doctors, but a lack of people allowed to even start to study to become one.

If you didn't cut the "limits" from the quote, you might've found a hint on how to answer your question without any magic involved. For such a small profession the general talent pool is endless indeed unless you... limit

Sorry, that is bollocks. That is the story most people believe, and makes for a convenient story for those people actually to blame. Funnily, it is also the story most doctors themselves seem to chose to believe in.

First, those are not the only choices. There is also the the option of training and hiring more doctors. 2

Probably, there is also an option of making more efficient use of doctors time, but that one is more complicated.

Most of the work of doctors is not life-saving.

I think, you see a standard problem of pushing shit down or up. Government lowers budget, pushes quotas down, which gets pushed down further until it reaches the bottom rank and file, the doctors.

They have to "do more with less" (Not limited to public sector, see Boeing), and that works for a while, until it doesn't.

> Most of the work of doctors is not life-saving.

Yes, but working out which parts are and aren't critical is the $64,000 question.

I think, that is a bit besides the point I wanted to make.

Yes, it is very hard to know a priori, what is life-saving, and what not. No, I do not wanted to suggest that the work of doctors it is not important.

The common understanding of doctors (their self-understanding included) is, that their work is very important, to the point that they exploit themselves. Or allow themselves to be "exploited".

In this forum, more commonly you have people here working on productive systems, which can empathize with the feeling the responsibility for the operations and not wanting to drop the ball.

People with that mindset think, they may safe a patient / the system, but working oneself to exhaustion won't solve those problems. And on the contrary, the exhaustion may be a contributing factor of making things worse in various ways. One directly by your actions, the other indirectly by covering up systemic problems.

Indeed. Is that weird mole just a weird mole, or is it skin cancer?

>They have to "do more with less" (Not limited to public sector, see Boeing), and that works for a while, until it doesn't.

Yes, which brings us back to the point I made about it being a numbers game. IF you start cutting back pilots sleep and planes' QA to boost profits, you'll reach the "it doesn't work" phase (planes dropping from the air killing everyone) much sooner and at a steeper rate than with overworked doctors where the decline is a lot slower and gradual hence why this issue gets ignored more easily by those in charge, because it's so slow that people keep getting used to this as the new normal.

IF a few Boeings fall from the sky, people might stop flying Boeings, but people won't stop going to the doctor just because some people get killed from malpractice (which is statistically more likely than dying in a plane crash).

It's easier for the public to recognize and be outraged about 237 dead airline passengers compared to 237 dead patients even if both are caused by overtired pilots or "providers" (I hate that word for it's vagueness).

I think having more physicians is the core thing.

The US stands out in having so few physicians per capita (per 1000 it's 3.6 in the US, here in Sweden it's 7.1, in Germany 4.5, Spain in 4.6). This has been discussed before here before, and I don't think it was controversial that a sensible solution was to simply have more physicians.

I think one major thing that the US is doing wrong with that which is not so well known is that the training starts rather late in life. Thus you get less out of the physicians you train. Here in Sweden a physician has a MSc in medicine and is ready to meet patients and be trained when he's 23, and I think this has the benefit that there's no need to overwork them.

By the time they're 30 they'll have all the experience the need without having been overworked, and not sleeping enough kills intelligence, memory, drive, all mental qualities one may have.

I think these two policies, ensuring that people graduate earlier-- removing the pre-med and having people start right away with a medicine program, and graduating in 5.5 years, that's the right approach.

Physicians would earn less, but they'd have substantially better lives. Being able to start younger also means success younger, and happier families.

This was in Australia (4.1).

Ah, thank you.

What about the meta-game, where doctors get burnt out or suicide, and that increases pressure on the remaining doctors, in a negative feedback loop.

We should impose work limits on doctors, just like pilots.

What I don't understand:

Say I'm a doctor, and I declare I will only work my 40 hours (or however much a full time is where you are). I will literally leave when my time is up. Oh, and I don't pick up phones outside of work. Or read emails.

What will anyone else do about it? Fire me? Then they have even less doctors...

It seems to me doctors do have the power to change things, even without collectivizing. But for some reason I don't understand, it doesn't seem to work out.

They would earn less money.

> the power to change things, even without collectivizing.

Not really it's a sort of prisoner's dilemma. The one who refuses to work stupid hours gets fired and someone else has their job. If they stood together then it might work.

But there is no one waiting for their job. In most places there is a shortage of doctors.

> Not really it's a sort of prisoner's dilemma. The one who refuses to work stupid hours gets fired and someone else has their job.

Is this relevant in a profession that already doesn't have enough practitioners?

I mean, let's say there is a shortage of 100 doctors in a location that currently has 900. If you fire one, wouldn't they easily pick up one of the open 100 slots?

The individual concerned is still fired and has a harder time surviving than the company that fired them.

There's a duty of care* that doctors have. If there's no one else to care for your patient, you're required by law to care for them. (I'm not a doctor, but it's a real thing) It's one thing to risk being fired. It's quite another to lose your profession.

*google "duty of care" for more info

If you don't have your own practice, yes, they might fire you. If you're only working "part time", you're bringing in less in patient associated payments for the owners compared to people who work more.

There's also the fact that doctors might prefer $700k/yr working 80 hour weeks vs $350k/yr working 40 hour weeks. A lot of people who become doctors are workaholics and were behaving in a similar manner throughout their schooling.

I think someone also did the math and figured out that having fewer handoffs side a patient led to better outcomes so now there’s pressure to have two doctors per24 hours instead of three or four.

That's a very good point. I think 12 hour shifts aren't necessarily bad, but even EMTs/firefighters (in some places, afaik) have downtime after their shift. Maybe work one on one off, or maybe 2 on 3 off. I suspect that's still much better than the practice of 24 hour shifts.

Did they really study how doctors and other staff work in enough countries?

Not so sure about that. According to a few studies, medical error is the 3rd leading cause of death, behind heart disease and cancer.

Many operations are elective. In such cases, having a tired surgeon or nurse may be worse than delaying the procedure, or even skipping it.

https://www.bmj.com/content/353/bmj.i2139

https://pubmed.ncbi.nlm.nih.gov/28186008/

https://journals.lww.com/journalpatientsafety/Fulltext/2013/...

This has been extensively debunked. Read the original methods of the BMJ article that you linked. They took every single minor error, like prescribing medicine 15 minutes late, and if the patient died, even of an aggressive cancer that they had already, it would be counted in the 'medical error that caused the death' statistic.

https://www.nytimes.com/2016/08/16/upshot/death-by-medical-e...

https://www.medscape.com/viewarticle/863788?scode=msp&st=fpf...

https://sciencebasedmedicine.org/medical-errors-2020/

Of course practicing doctors and nurses are going to swear up and down that it isn't true. They are the perpetrators. Ask any person who has had to spend time in a hospital recently, and watch your "de-bunked" turn back into a "re-bunked." These jokers can't even keep the charts straight. It is fast-food-tier service for a life-and-death commodity.

…but if you postpone a procedure, the medical facility they work at isn’t able to keep up with their revenue targets.

IMO this is doctors acting as enablers of a toxic administration. They need to refuse outright to not work crazy hours and force the system & administration to come to a crisis. The admins are not working those hours and thus do not feel the consequences of their actions and by enabling their bad behavior they are not getting consequences from their bosses, which are politicians and customers.

I think it's a matter of the 'tradinionalist' mindset in doctor education

most doctors will think "well, I went through a hardcore intesnse experience in medical school, therefore that's how it should be"

I'm saying they've normalized overwork as part of their specific subculture of modern medical professionals. they really believe they won't be as good doctors without this arguably abusive overwork system

it's yet another group of people who all belive in some form of the "no pain, no gain" mindset; the issue is these groups don't give nobody anything unless there's some harm or pain involved

> If your operations have a 90% survivability rate it could still be considered a success despite those 10% they end up killing, because 90% is a lot better than 0%.

> Meanwhile a tired pilot is more binary, it either can have 100% passenger survivability if things go well or 100% fatality if things go tits up, meaning the risk are too high to take chances.

This isn't how the math works. A tired pilot either kills or doesn't kill their passengers on a given flight the same way that a tired doctor either kills or doesn't kill their patient in a given operation. In both cases it's 100% survive or 0% survive.

Pilots aside, we also have laws about keeping truck drivers from driving too many hours, and accidents involving drowsy truck drivers are unlikely to have fatality counts measured in the hundreds.

The difference between doctors and pilots/truckers isn't in the amount of risk involved, it's that surgeries are expected to have a non-zero fatality rate. A doctor can do their job perfectly and still lose a patient, so it's harder to prove that the fatality rate would be lower if we gave surgeons more rest. When a truck driver falls asleep at the wheel and kills someone it's obvious because they did something provably illegal or unsafe right before the crash. When a surgeon fails it's a lot harder to prove it was preventable.

It's a little different because an unflown airplane doesn't kill people, but an untreated medical condition does.

Sometimes it can happen extremely quickly, but also be largely preventable with proper and timely intervention (like with a burst appendix).

Complicated question, on potential factor: maybe because the doctors kill one by one instead of in batches, so the ridiculous artificial entry limits that result in very high workload, but results in artificially high pay, doesn't meet a strong enough force to be adjusted?

> The question is, why is it okay for medical professionals to wear themselves down to the bone (sometimes literally, like in this article), while some other professions take care to avoid it?

I think the answer here is that if you there aren't enough pilots, schedules can be reduced. You can't scale back (in any ethical way, anyway) the demand for healthcare. People will just die at a higher rate and outcomes will worsen.

Thank you for your comment, that's a very good point. I self-replied a bit lower with more discussion on this, primarily to the effect that the "solution" in that case would be to hire more doctors. The concept of a "standby" doctor (like a volunteer firefighter) could be used (more), for eg retired former doctors/nurses.

There is a lot of protectionism & abuse in the doctor system, to the point where I think common tropes are put as fronts to keep up a status quo to hide the reality. You have to look at actions vs. the statements at this point. "The purpose of a system is what it does"

Statement: We need more doctors in Canada.

Actions: It's much harder than 20 years ago to get into med school or a residency (USA medicare). It's even harder to go to med school in Canada than the USA! Doctors from other countries have much higher testing standards than local med school graduates in Canada to get licensed. To the point where they move to the USA because it's easier to start working than it is in Canada itself. Foreign Doctor moves to canada and becomes a taxi driver is a trope in Canada because of the excessively high barriers.

I share the same objection about the lack of regulation in the medical profession worldwide.

My best friend from high school became an MD and I witnessed doctors in training being proud of powering through extremely long, back to back shifts with little rest.

Meanwhile, as an engineer I've seen short and strict shift limits on employees operating machinery like trucks and forklifts. Under the obvious principle that insufficient sleep impairs judgement, put lives at risk and creates massive liability.

For inpatient hospital care, research has shown that transitions in care are particularly risky for patients. When one doctor goes off shift and hands off a patient to another doctor, sometimes things fall through the cracks. In theory all of the data needed for a smooth transition should be documented in the patient chart, but in practice this doesn't always get done plus there is some tacit knowledge which clinicians build up by observing a particular patient which can't be put into words.

This risk of iatrogenic harm has been used to justify long hours, particularly for residents in teaching hospitals. I'm not saying that it's necessarily a good idea or that there are no better alternatives, just explaining some of the rationale.

Thanks, I commented a bit above already to a similar response. I would say that there's a balance between very short shifts and 24(or more) hour shifts. 12 hours for example is doable occasionally/with breaks in between shifts. Right now the pendulum is at one extreme.

[0] - https://news.ycombinator.com/item?id=40025540

I haven’t read that literature very closely, but will say that I have seen lots of handoffs, and they generally involve someone who has been working 12+ hours, very often 24+ hours, who needs to hand off 10s of patients to 3+ people, all of whom have things to do and can be hard to schedule around, before they can go home.

It is not at all surprising to me that these kind of hand offs result in things being missed, and equally obvious that decreasing the patients per provider and increasing hand off window hours would at least reduce some of those errors, if not outright improve them. Bonus points for putting the peak of handoffs into late morning hours, where much more of the decision making is completed.

Of course, the only way to do that is to either:

1) drag hours out longer, which I think lots of MDs would be fine with if they weren’t expected to turn around and do it again in 18-36 hours, requiring increased staffing

Or 2) increase staffing all around and just maintain more reasonable ratios

It's even worse. In the EU the working week is to be an average of about 48h. ...unless you are an medical professional, then you "may" opt-out and work up to 78h. It's completely legal, and regulated by the law of the EU:)

https://www.europarl.europa.eu/meetdocs/2014_2019/documents/...

The cynic in me says they have bad working conditions since they're public funded: governments, to a large extent, don't want to increase or divert taxes to provide better working conditions since they'd rather give their friends in the private sector a slice of the immovable and highly lucrative pie.

A partly-privatised healthcare system only works when all agree to balance the intangible long-term benefits of universal healthcare with tangible private-sector financial-gain. I don't see this happening when the private sector is seen as the panacea of all social-ills and when universal healthcare isn't seen a means to increase productivity.

The answer is implied, right there in the first paragraph: "... I’ve never been diagnosed with a mental illness."

At least in the US, there's a kind of masochistic pride in the physician community, that everything he described in his essay is laudable, noble, to be emulated. Nowhere does he acknowledge the risks to his patients or whether the costs are worth it in the end, or if a different system might be better. And he's holding up the lack of mental illness diagnosis as if it's something to be proud of, as opposed to never being diagnosed with say, cardiovascular disease or cancer. He's proud he's never sought help or tried to change anything. Sure he mentions problems with patient care in passing, but what he's really upset about is "just being another employee".

In the end in his mindset whatever he's complaining about is better than the alternatives, which is ceding over some of the care responsibilities to others or opening up healthcare to a more competitive market so he's not the only provider who could provide those services (note the comment about denying other physicians income). The AMA and physicians union (yes it's a union) basically guarantees this in lieu of having real competition, decreased income, and so forth.

Why is it different in something like aviation? My guess is because the failures are more visible, they're on the nightly news, people are there posting pictures on social media? For whatever reason, I don't think pilot organizations ever managed to remove themselves from scrutiny in the same way as physicians did. We see pilots as highly skilled professionals, but part of a system, with alternatives, and the subject of fair scrutiny from outsiders who are not pilots: engineers, safety experts, investigators and so forth. In my experience when these kinds of issues come up in healthcare though, everyone defers to physician groups themselves, as if no one else has expertise enough to scrutinize them.

I imagine too at some level, part of the issue is that the pilots themselves are subject to their own mistakes: if a pilot crashes a plane, they take themselves out at the same time. If a surgeon makes a mistake and kills a patient, they still walk home and can rationalize whatever they want, all they want.

I'm growing unsympathetic to these types of essays (the one linked). If physicians want me to empathize with them more, maybe they should stop stigmatizing mental unwellness and recognize it in themselves. Maybe they as a professional group should admit that others could take on some of the load, maybe even better in some situations. It feels a bit like they create a mess out of selfish greed or ego and then expect me to feel bad for them.

> Nowhere does he acknowledge the risks to his patients or whether the costs are worth it in the end, or if a different system might be better

c.f.

"...everything is rushed, and mistakes are bound to occur."

"I am realising more and more that what brings me greatest distress is the relentless administrative pressure which take away the meaningful clinical engagement I have with my patients."

"I was burned out and I couldn’t control my emotions at work and at home. I’m not inherently an offensive or rude person, I’m just a person pushed to the limits and set to fail because of the circumstances around my work."

> In the end in his mindset whatever he's complaining about is better than the alternatives, which is ceding over some of the care responsibilities to others or opening up healthcare to a more competitive market so he's not the only provider who could provide those service

This is Australia, which does not have artificial restrictions on the supply of doctors to the same extent. On the other hand, they don't have a surplus of surgeons nor can nurse practitioners do the work

> (note the comment about denying other physicians income).

Yah, he's saying that if he doesn't come in, the backlog gets worse, and other people don't get paid.

> He's proud he's never sought help or tried to change anything.

He says he would like to seek support, but highlights the structural problems that prevent it:

"I know where I can get support, but practically, when and how am I going to get that support?"

"In addition, doctors who scream for help may be formally reported, therefore having restrictions placed on their practice and then incurring higher medical indemnity fees in some situations. Trainees who ask for help may be labelled as underperforming and have to be commenced on probation or remediation. We may not have practical access to the support that are often advertised."

I absolutely am in agreement with you that the things done to artificially lower the supply of residency training in the US are terrible. But those criticisms don't seem to apply to this essay.

> which does not have artificial restrictions on the supply of doctors to the same extent

Yes it does. One of the really interesting questions is actually why the same problems have been created in so many otherwise-different systems.

Edit: a post giving details on the Australian medical training constraints https://www.aph.gov.au/About_Parliament/Parliamentary_depart...

> > to the same extent

Your source says that the government sets (indirectly) a limit on the number of places at most public universities, but there are private, full-fee universities that are not so limited.

Internship slots, in turn, are set by disparate government agencies. They've climbed, but probably not climbed enough.

Compare to the US, where congress basically directly controls the number of residency slots and has failed to increase them really at all to keep up with increasing population and increasing need for medical services.

This is just wrong. The supply is absolutely artificially capped, particularly for positions like surgeons. This is controlled by the Royal Australasian College of Surgeons in combination with government funding. There is no “private, full-fee universities that are not so limited” alternate path; don’t make stuff up. Source: Brother in law who is a surgeon.

> This is just wrong. The supply is absolutely artificially capped, particularly for positions like surgeons.

I feel like you don't understand the distinction about positions at universities for initial medical training vs. internship and residencies, which I believe I discussed fairly above.

see

> > Internship slots, in turn, are set by disparate government agencies. They've climbed, but probably not climbed enough.

"Disparate agencies" isn't great phrasing, though, as what I really mostly meant was "each province".

To start with, you’re overestimating the role of full fee paying university places, Australia doesn’t have provinces, and the intern year is not equivalent to an American internship - that’s the registrars, and there are fewer of those than internships. (This is the position you need to get in order to begin any specialty training, such as surgery. They are very explicitly managed and funded by the federal government. https://www.anao.gov.au/work/performance-audit/administratio...)

More generally, Australia does have states and territories, but the federation model is far more centralized than the US: for instance, public hospital funding is a shared pool coordinated by federal agreement. https://www.publichospitalfunding.gov.au/victoria-basis-nati... While the vast majority of internships are at public hospitals, the federal government also pays directly to create a relatively small number of internships at private hospitals.

But of course this is all largely irrelevant because about one third of doctors in Australia completed all of their training in another country, and were then awarded a visa based largely on their profession being listed as a national priority under the system managed by the federal government.

> At least in the US, there's a kind of masochistic pride in the physician community,

But the question is why does the rest of society insist that pilots be properly rested but not doctors? I'm sure a lot of pilots would also work crazy amounts of overtime if allowed.

Pilot failures are really visible, and kill hundreds atll at once. Bad medical decisions lead to more deaths overall, but it's far less likely the public will hear it, and even if they do, it's one person at a time.

Far more people die from car crashes than airplane crashes too: It's not even close. And yet, people who have no business behind a wheel drive, and the penalties for being a poor driver are typically minimal. Same difference.

And the pilot is quite likely to die in any fatal pilot error, so there's an element of self-interest in preventing pilot error.

When a pilot or a truck driver fall asleep, it’s easy to see the cause and effect. When sleeping, they can’t control the vehicle.

With other professions, the people are awake, their brain just isn’t functioning properly, so it’s easier for people to ignore the true cause, since well rested people can make mistakes too.

Not only pilots. Truck driver resting time is heavily regulated to the point the need to record start and end or they will be fined at best. Their employers will also be on the hook if drivers are non compliant.

A truck driver! But doctors? No… they are Uberhuman and can make life or death decisions after 24 hours on call and awake. Ridiculous. It is a topic that angers me a lot.

This happens in Portugal as well as Poland, it indeed feel universal. I think the reason is that doctors are kind of like gods: in the hour of your biggest need it is them that can help, therefore they are highly respected and have huge influence over a wide cross section of society. Everybody will eventually need a doctor in their life.

Another pet outrage topic related to doctors is the amount of time they need for training. They train almost 12 years after high school before they are qualified. What a wasteful training. They learn lots of generalities to the specialize in the end. With a 10 or 12 year higher education you are speaking about phd or post docs for a profession that requires 1 for every 1000 citizens. Imagine that ratio of phds and post docs. Is being a GP really requiring such training? I don’t think so and agree with above posts that their duties should be broken down, opened and delegated.

Because when there is no pilot, the airplane simply does not fly. Nobody dies, there is just an economic damage. But if there is no doctor, people still get ill, and then people die. Which makes it ethically easy to impose the one but not the other. And which is also the reason why pilots can go on strike, while the same is much more limited for any kind of (medical) care job.

I would also add the famous Bert Cooper line, "I never heard the word client in there." He mentions patients, but they are all wrapped up in a woe-is-me section I work so hard and yet I haven't been diagnosed with a mental illness.

He sounds like the kind of person that brags about being mentally sound but is secretly addicted to benzos. Always advocate for yourself!

It's different in aviation because the pilot dies too when the plane crashes.

I think it has to do with the cost structure of the good. Healthcare is dominated by labour costs, which means in industrializing economies it lags behind in productivity and labour starts getting squeezed to try and keep prices at a reasonable level. A pilot, despiute being in a highly skilled profession, is only a small part of the puzzle when it comes to the cost of flights.

My assumption is that is a doctor does nothing the situation will get worse. So therefore them doing anything is seen as a step in the right direction, they will improve things over the base line?

A pilot isn’t in charge of a deteriorating situation, then doing something could make things worse below the base line (a tiredness induced mistake) so therefore make sure the only do stuff when fit to do so?

Note I’ve used questions on both of these examples as it’s more of a half thought and a feeling that a statement or fully fleshed out thought.

I guess the summary is, I’d rather have a tired doctor work on me in an emergency than no doctor work on me. I’d rather not fly on the plane than have a dangerously tired pilot fly the plane.

That’s being said the system clearly needs improving and we need more medical professionals to balance the work load.

Compared to aviation, bad outcomes in medicine are a) not news material and also b) taken into account beforehand.

Phobias apart, we simply do not expect to die, when we fly. In contrast, we openly consider % survival rates of medical procedures. These rates have human error already baked in, and would be lower if humans made less errors. And then there is the primal fear of not getting help, if needed, because no help was available, which certainly works on our collective will to action here.

A 50% survival procedure for medicine might work, because it's either that or death. Aviation is always a few plane malfunctions (not even outright crashes) in quick succession away from the entire industry crashing.

My partner is a surgeon in the UK. She's planning on leaving the profession at the end of the year. We talk a lot about what is wrong with the medical profession.

One issue is the type of person attracted to the profession. They're incredibly academically talented, not driven by money, and desire status and recognition. Surgeons are the most extreme cases of this personality type, as they're harder jobs to get and have a lot of pressure. These people are the types who get their head done, roll up their sleeves, and get on with things. They're not used to asking for help or additional resources. They're the sort of people who care for others! Medicine self-selects for martyrs.

In addition, you have so many hoops to jump through (training, specialisations, etc) with significant time investment that can be lost in moments by pissing off training directors or other senior doctors. My partner ends up working more than her contracted hours because her bosses expect her to, although they would never explicitly enforce stricter rules. If she works her contracted hours she can kiss a consultant job (UK equivalent of attending) goodbye as her bosses won't provide a reference for the role.

Because the stakes in medicine are literally life and death, meaning that it is heavily regulated. There are horror stories around the GMC, the UK regulator, and doctors are terrified of being investigated. They adopt a legalistic mentality where they only treat if they're sure that they won't get prosecuted. It's very different from aviation with its no blame culture.

Finally, another factor that is making medicine so tough is that it is a success story! People live longer, and pathologies that were once fatal can be managed with ever more complex treatments. As demographics lean to older populations, then the demand keeps increasing.

I've looked at all the other replies and very few mention the obvious: self-regulation is hard.

Hospitals are mostly held as public services, and having more doctors better handled arguably costs more (in training, infra, shift management etc). Gov gets to decide if it wants to pay more, or even change the status quo and bails on it.

It's the same deal for teachers in public schools and other public servants, their mental health management is lagging, their salaries and treatment as well, dispatch and promotions are a PITA etc.

I don't think govs are inherently bad at it, just that there's no check and balances most of the time. Same way private companies are bad at self regulation and need an external force to get regulated. Mandatory unionizing and better avenues to sue for better conditions could be an answer?

> I had worked in a hospital where I was oncall 24/7, 12 days out of 14. I had fortnightly weekends off.

Why would you do this? Some of the most basic labour jobs have better employment terms than this.

> You might ask, why can’t you work less? It’s not as easy as that. If I decide to work less, who is going to cover the hospital?

Yes, I did ask. But covering the hospital isn't your problem, that's a hospital management problem.

> If the hospital aren’t employing other doctors, we can’t allow patients to go uncovered.

It's the hospital that's allowing patients to go uncovered if they don't employ enough doctors for a reasonable workload.

The author goes on to detail just how unreasonable the workload is.

> As a surgeon I spent a year in a hospital where I smiled on the way to work and I am so grateful for my job. I looked forward to long days because I knew what I was doing was significant.

So there are cases where it can be enjoyable, yet ...

> Another year in another hospital, I dreaded going to work. I hated being on call....Same surgeon, different jobs.

I don't see why you'd choose to work at the dreadful job. Isn't surgery a skilled labour job that is in high demand? How can they not demand more control over their working environment?

I'm guessing, but maybe it's possible that they're conditioned to accept increasingly stressful environments from the first day of med school. So that by the time they're surgeons, they're so conditioned that the idea of refusing the unreasonably stressful load is not even fathomable. Maybe there's even a certain amount of egotistical satisfaction that comes from being able to hack it.

I know a few doctors, and you have to keep in mind a lot of them are good people trying to help others as much as they can. They put up with overworking because at the end of the day, they want to be there for their patients as much as they can be, and if it's not them then people would literally not get the chance to see a doctor at all.

You are right, it shouldn't be their problem, and we should work on making sure they're (especially surgeons for christ's sake) well rested and as stress free as you can be in a field like medicine, but what's the alternative for them and their patients right now?

Because they actually care about the patients and the work is critical?

You can’t just job hop like in tech?

It’s like everyone on this site views the whole world through a super narrow “tech worker” lense and assume every job works the same and everyone has the same motivations as people in tech

> Because they actually care about the patients and the work is critical?

That's not a good reason to be overworked to the point of extreme misery and possibly suicide.

You can care about your patients, do critical work, and still have a workload that is reasonable.

As the author said, there was one job that was much more enjoyable. I'm sure they cared about the patients in that job just as much as they cared about the patients in the miserable job.

I understand why doctors don't just refuse to come in. It's horrible but one of the only ways they will see change is by refusing poor working conditions. The sociopaths that own the businesses know that doctors feel that way and will milk it for every hour of extra work they can get. It just doesn't matter to them what anyone feels or complains about they are soulless demons who understand metrics and nothing else.

There has to be a way for docs to organize in larger groups and demand better, including striking when it comes to it.

The three factors mentioned (loss of control, loss of support, loss of meaning) are the pillars of occupational burnout, according to researchers like Christina Maslach.

In many cases, someone experiencing occupational burnout NEEDS extended time away from their work environment to heal. In severe cases, they might not be able to return to work at full capacity for years (or ever). This creates a negative feedback loop for understaffed doctors, nurses, and other healthcare workers.

I have no sympathy for doctors. They are a part of an exploitative system, and they know and accept it. Most of them are in it for money, in the first place.

The experience that the author describes is not much different than a fancy lawyer's or that of a Wall Street finance person. They all knew about the long hours, but money is more attractive...

Many only accept it because there is little choice but do so if they wish to pursue the profession. Despite what you may think, many are not in it for the money, but genuinely enjoy their work (but wish it was fewer hours) and helping patients.

In the U.S., some hospitals are seeing residents and fellows truly refusing to accept the status quo—they are voting to unionize in hopes they will be able to finally upend the exploitative system (at least for trainees).

This is what happens when everything is financialized. There is no reason that we should be running doctors into the ground. Health professionals are a necessity in a functioning society. I know in the US Government seems to have no problem throwing money at corporations and providing endless tax breaks. But god forbid we proved a functioning health system.

For the US this needs to happen.

1) Medicare For All - a universal, no pay at service, insurance system, everyone taxed at 4% for it.

2) People that have the grades to make it to medical school should get a free ride.

3) Small Private practices should come back with free digital billing with the new health insurance system.

4) Price regulation on all basic medical supplies and medicines. No more $20 tongue depressors

5) All medicines researched at public Universities will not be sold or given to private industry. They will be licensed. That money goes back into supporting this system.

Public healthcare doesn't work.

They just get progressively worse and start adding expenses for the patients. The quality is terrible, despite the propaganda. The best companies were offering private healthcare with their offer.

I've seen it happen in two countries, now I live in one which just made most of private healthcare (which is excellent quality) available as public. It's working well for now but they're spending a ridiculous amount of money and it's not sustainable. Doctors are happy, I'm not because my taxes increased from 12.5% to 15%.

Public mismanagement is huge, they'll screw it up.

The USA government needs to stop being in bed with insurance companies to make everything expensive, then your private system will be fine.

I didn't say Public healthcare. Only the insurance is public. The healthcare system still stays private.

> Public healthcare doesn't work.

It works here.

It appears that Dr. Eric Levi works in England.

I don't think you've done the math on that. Healthcare constitutes 17% of US GDP. A huge chunk of that is paid by self-insured employers. An additional 4% income tax wouldn't be sufficient to fund a "Medicare for All" program. Any further increases in income taxes would be highly regressive for low-income people. And the baseline Medicare program doesn't even cover a lot of stuff that is typically included in private medical insurance such as prescription drugs (need at Part D supplement for that).

That 17% includes Net cost of health insurance. So that would go down a lot with the profit taken out of it. Also expenditures would go down with price regulation and the system would also generate money from licensed medicines. Also the simplified billing and administration of a single insurance system would save a ton of money. Especially since a lot of the overhead in hospitals is admin. This simplified billing would let doctors have private practices again.

https://www.google.com/search?q=what+make+up+GDP+healthcare+...

You're dreaming. Commercial payer organizations have low profit margins, especially since the Affordable Care Act (Obamacare) instituted an 85% minimum medical loss ratio. Some of them already operate as non-profits. Eliminating them wouldn't free up nearly enough funding to make "Medicare for All" work with a mere 4% income tax increase. Do the math.

"low profit margins"

Health insurers raked in more than $41 billion of profits in 2022.

https://penncapital-star.com/uncategorized/americans-suffer-....

You appear to be confusing margins with absolute amounts. Eliminating all health insurance profits wouldn't be sufficient to close the gap on your "Medicare for All" proposal, not even close. I'm not necessarily opposed to a single payer system, but you need to do the math and be realistic about costs.

(At least some) of the new generation of doctors appears to be better about refusing overwork. AFAICT that's a large component of the doctor shortage here in Canada -- the ratio of doctors to patients is better than ever but if a doctor "only" does 40 hours a week you need more of them.

I know America strictly limits the number of people who can become doctors every year. Does Australia have a similar system?

It seems insane to me to first limit how many there can be, and then overwork the ones you do allow to become doctors.

>I had worked in a hospital where I didn’t get home for days at a time, sleeping overnight in hospital quarters, outpatient clinic benches and in my car. I used to have my sleeping bag, toiletries and change in the boot of my car because I didn’t know if I was going to make it home some nights. Plans change every single day at work because of emergencies. I can’t even be sure what the next hour will bring when I am on call.

This is absolutely insane. Are we reading a town doctor's tale or a war tale?

Though significant restrictions on supply do exist, the problem does not seem to be nearly as bad in Australia as in the USA [1]. In Australia there's ~15 medical graduates per 100k vs ~8 in USA.

The doctors in Australia are still definitely overworked though. A decent number of the people I went to school with became doctors in Australia, and though we work roughly the same number of hours (~60-70hrs/week), my work in the software industry is like a stroll in the park.

It was remarkable to hear my male friends who became doctors admitting that they had broken down crying in meetings with their boss because of workplace stress and exhaustion.

1. https://www.ama.com.au/ama-rounds/13-may-2022/articles/more-...

there's more than 12 times the number of people in the US. Yes i understand this is "per 100k", but this still kind of reads like "adding lanes to highways does not reduce traffic," and that means that there is some other issue. If you have more doctors, more people will go to the doctor. This is good, more people should go to the doctor, because early and preventative care reduces the overall cost burden on the system.

And i don't want to put this in its own comment or even continue reading the defense of doctors (as they stand now): Women get shafted so hard by the medical community. People with mental health issues get screwed by the medical system. Both get their problems written off for non-medical reasons. There are bad practitioners just like there are bad developers and bad general contractors and bad bridge builders and bad pilots. The whole system is not very good and i don't see, necessarily, how merely adding more medical degree holding people to the mix will improve things. There isn't enough patient advocacy, there's too much friction with medical insurance (in the US).

But at least the shareholders are making money.

Why do you work that many hours?

For fun.

While it's true that there is a limit (really there is a limit to every university study), there is also a limit to the number of people who are qualified and interested.

For instance, there are only about 20k people who score > 510 on the MCAT per year (the average matriculant has about a 512). And remember that includes US & Canada.

While I know there are a lot of people rejected from medical school each year, some probably should not be accepted to medical school. I think we could probably increase the number of seats by about 20%.

The American and Canadian medical schools place a high bar on accepting students, so nearly everyone who is accepted graduates. It's uncommon for medical students to perform poorly.

But this isn't true everywhere. Some places prefer to admit many students and let them sink-or-swim.

> there are only about 20k people who score > 510 on the MCAT per year

The article clearly shows the skills necessary to work as a doctor are a lot wider than academic ability.

One pleasure/pain of being a software developer is that there is less gatekeeping.

> The article clearly shows the skills necessary to work as a doctor are a lot wider than academic ability.

Where does the article show this?

Certainly. My point is that there isn't an unlimited pool of qualified candidates.

There are things other than academics, but that makes the pool even smaller.

Its not just limiting the numbers, but also the way matching is done. The current way is that upon admission to med school, you must be willing to accept just about any practice specialty. This is another thing that could be flipped on its head by allowing you to be any kind of doctor, provided that you attain the required MD and complete training.

Yes, I know, certain medical specialties are very competitive, but (IMO) they should be forced to admit you if you pay for the training. For instance, if I could be a radiologist, I would. But I dont want to be any other kind of doctor. They could say "ok, you will be eligible for radiology residency upon earning an MD and completing some standardized program proving you learned the book-side of radiology. Upon completion of that, (and , say 1 year of generalist MD work), then some radiology residency essentially has to admit you. Not interview for it, and jump up and down like a puppy, and based on how likeable you are, maybe, they let you in.

This could open the door for non-traditional doctors in general: Word could get around, "hey, this podiatry program is cool, 2 years training, 1 year public service, and you could earn $200k", knowing what kind of dr you will be might have an interesting effect in attracting people who otherwise would have never considered it (to fill the unpopular specialist roles like podiatry or psychiatry).

I would like to ask anyone who knows medical policies: can we not have cap on accepted medical school matriculants each year? Can we have a system where if you are qualified to attend medical school, let as many of them attend as they can so free market mechanism plays in this career path just like we have in graduate school?

This will get you started: https://www.niskanencenter.org/the-planning-of-u-s-physician...

Thanks for sharing. This is so disheartening. The other day I was debating with my friends how a doctors life is so cool that they don’t have to go though grueling coding interviews every single time they want to change jobs, don’t have to prove themselves every single quarter, don’t have to be answerable to anyone or write performance reviews or be subjected to arbitrary rubrics. Boy, I was so wrong. Every procession has its hazards. This has been a learning for me. Although I do feel that the PCP doctors in US seem to have a simpler life. They leave office at 5 and don’t take calls in the night. Happy to be corrected though.

Even PCPs sometimes have to go home with the knowledge that someone died, and (being human) wondering if there was something else they could have done.

Now imagine that happening dozens or hundreds of times over the course of a career.

Unless coders are working on air traffic control or something similarly critical, it's pretty rare for a bug to kill someone.

US PCP doctors do take calls. It's less common for them to go to the hospital to admit their own patients anymore since the rise of "hospitalists" but they still take outpatient calls and calls from the ER.

Also, PCPs are subject to the most metrics/rubrics of any, and all the crap paperwork that any specialist can foist off onto them, they do. Shit rolls downhill, and PCP's are at the bottom

They may stop seeing patients at 5, but they sure as shit aren't done at 5. Most are logging back in even later doing all the "paperwork" they didn't have time to do during the day. Even has a nickname: "pajama time"

I get what you mean, but doctors also go through a decade+ of medical school+being on rotation. Lots of devs out there (myself included) without even a bachelor's.

Same reason why classical engineering fields don't do anything like leetcode, those engineers are actually accredited.

One point I resonated with is the high administrative overhead of being a doctor. I can imagine the stress of using an outdated EMR system when the time you have for each patient is so limited. I see lots of AI companies are trying to transform the MedTech industry, but I'm unsure how much of their products useful / are actually adopted by the hospitals. Maybe some experts in that space can enlighten me on that?

I also agree that running hospitals like a private business is at odds with the essence of healthcare. However, this trend might be more indicative of a broader societal shift rather than a phenomenon unique to this sector.

One of my old registrars co-founded this company: https://tortus.ai. They are doing a trial at Great Ormond Street at the moment - I haven't tried what they're building but it's an AI assistant that reduces some of the admin burden.

I am really hopeful that systems like this will take off – the reality of being a junior doctor in the UK is that most of your time will be used on quite tedious admin tasks (documenting every patient interaction, filling forms, booking clinics etc.) using very & slow outdated computer systems. I don't think anyone expects this when they apply to medical school, and it can be quite demoralising when you start your first job.

> I see lots of AI companies are trying to transform the MedTech industry, but I'm unsure how much of their products useful / are actually adopted by the hospitals. Maybe some experts in that space can enlighten me on that?

My impression (as an outsider with a partner in the medical field) is that the prime function of the "medical industry" is to generate reams and reams of documentation about "care provided" to an insanely granular level. Functionally, this information is mostly bullshit that is irrelevant to providing medical care, but it serves a very important purpose for the medical administrative class so that they can bill the patient for each bandage applied or Ibuprofen administered.

AI MedTech companies mostly seem primed to increase this firehose of bullshit. Whether or not that will take the pressure off front-line medical personnel who are currently tasked with generating it remains to be seen, but you'd be hard pressed to convince me.

There are a few other reasons - doctors document every interaction partly for medico-legal reasons – just in case something happens. The notes become especially long and defensive in any situations that have a possibility of being misinterpreted. If it's not written down, it didn't happen. It's obviously also a record for other clinicians / healthcare professionals to read through and see what happened during the admission.

But yep I do worry about any kind of generative AI in this context.

Even before AI tools started becoming available, some provider organizations hired human medical scribes (documentation assistants) to do EHR data entry so that highly paid physicians could focus on patient care.

https://www.ama-assn.org/practice-management/sustainability/...

AI can partially automate the scribe jobs to deliver a minor productivity boost or cost savings. But the near-term prospects for using AI to automate care delivery look pretty dim.

> the stress of using an outdated EMR system

Using an outdated EMR system is hardly a cause of stress. A more usual cause of stress is being forced to use a brand new (and unusable) EMR.

It's a bit scary how mostly smart people writing here seriously believe doctors are a "cartel" blocking preparing of new doctors. It's scary how you just ignore obvious facts like that the problem is present in any developed country. You really believe there is an international mighty cartel of doctors, what could influence like governments and private universities as well? Even would it be so, who would benefit from the lack of doctors? It's bad for simple doctors, because the workload is greater, it's bad for doctors in leading positions, because finding new staff for their teams is more difficult, and it's bad for patients, because the doctors are chronically tired and worn out and in some areas they even got a problem just to get an appointment soon enough, because local doctors are overloaded and got a full shedule for many months in the future.

The explanation of the situation is not a mythical cartel, but the simple facts: - Any additional place for a medical student at a university costs a lot of money, and nobody wants to spend money to fund its creation. - The people in developed countries get on average older and need more medical service and consequently more working hours of doctors. - The quote of women among students is constantly growing. In my country Germany we had ca. 70% men and 30% women among students like 30-40 years ago. Now the quote is like 70% women and 30% men. Nothing bad at that, but a lot of female students get soon a family, a bunch of children and since that never ever work full time anymore.

Stastitically we got so much doctors as never before in the history, but the sum of working hours in the country is lower, while the needs are getting higher because of olding population.

> influence governments

Healthcare providers spent the most money lobbying the US government for decades:

https://www.opensecrets.org/federal-lobbying/top-spenders?cy...

I am a working physician (50+) that is currently in training to become an IT professional, preferably working with development of new patient records systems. Being a physician is just not very intellectually challenging, more emotionally challenging, programming is in my mind a real challenge. Any others with experience of changing fields?

I'm an anesthesiologist. Two years ago I switched to doing 100% software engineering. I had already worked in software, but not full time. There were many reasons. More time with my family was a big one. Work not being intellectually challenging was a another.

Having worked in software before must have made it easier to change profession? I have not so I think I need formal training, I am a programming hobbyist writing in python and did some SQL for databases for research. I guess I need to have really tough problems to solve, when I succeed, there is almost nothing like it, the feeling of accomplishment.

I had already contributed to some open source projects and had also done some fairly large freelance projects. I'm sure this made me more hireable.

I'm not sure I will give up anesthesiology 100%, in the end I'd like to combine and work on "medtech". Currently I work with automotive radar.

Feel free to reach out!

Thank you for the response! I also feel this way, I still like some aspects of being a physician. I think it's just the way some of us are built: we thrive on learning new things, we enjoy challenges and we get bored when stuff gets too easy. Automotive radar sounds exciting as well! I will look for open source projects, it might be a great way to get work experience, thanks for the tip!

Moved to IT (in a pharma context) after 5 years of experience in hospitals by chance. I like to tell myself that I gra itated towards it since I always wanted to be an engineer. I will not stop being a doctor and I may never quite be an engineer, but I enjoy what I do.

I trained as a doctor, then family practice for a few years, but since the middle of my studies, I realised my main passion was the more technical aspects. I did a bachelor's in electronics engineering while working 50% as a doctor the first two years, and with the last year dedicated only to studying. I realised a bachelor's would not be enough to get the engineering jobs I desired, so I went back to medicine and started training as a radiologist. There they agreed to fund me doing PhD research 50% of my time, and I am now doing a PhD using AI diagnosing dementia from MRI scans--basically my dream job, while working 50% as a radiologist which also is fun and intellectually very rewarding.

Wow, that truly sounds like a dream job! I discovered neural networks in 2017 and managed to write a simple app to scan dermatological images to classify them, amazing technology! I have worked for one year at a dementia diagnostic centre as a part of my training to become a specialist in family medicine and there is definitely a lot of interesting work to be done. I have also have an interest in radiology, how are you finding the profession so far?

I like it a lot, as I mentioned intellectually rewarding and I feel like most of what I learned at med school is useful. I also quite enjoy the occasional increase in adrenaline when at trauma reception or stroke CT evaluation. Also nice to both be able to work in peace and collaborate with clinicians. And personally I also enjoy keeping up to date on research which is evolving quite rapidly. The negative aspect is mostly what is common to most medical specialities and due to understaffing.

> preferably working with development of new patient records systems.

That field is quite a mess. There's a oligopoly of few large vendors with low quality products but high quality politics and sales. Although as a working physicians you're probably familiar at least with the results.

Edit: Further discussion, including EHR system developers, here: https://news.ycombinator.com/item?id=39186252

Having been on the user side could be a major upside for improving the efficiency of the systems, but I'm afraid the business model of EHRs don't really allow for improving the systems much.

EHR is truly a mess which is why I feel compelled, as a somewhat computer-skilled physician, to try to do something. There is a lot of potential to improve EHR but I think we have to start from scratch with a completely new way of thinking. It will be very costly but current solutions aren't working to help the physician, it just adds to the workload.

The business models of EHR's I'm not that familiar with, I will read the thread you provided, thanks! It sounds like you have experience working with EHR development?

> It sounds like you have experience working with EHR development?

Not first hand, but I followed it quite closely when we as activists tried to prevent Finnish healthcare from getting an Epic based system (that turned out to be exactly the disaster we predicted).

Well done! Epic Systems sounds like a nightmare corporation, ruining the lives of health professionals all over the world.

The sad thing is that there is an optimal number for working hours for employees in "potential emergency jobs". It is around 85% or so. (I forgot the source, I think it was Gerd Gigerenzer on managing risks.) This way, they can handle most emergencies in a good way.

Reality is that many doctors in a hospital work 120% already. This either kills the doctors or the patients.

The issue is that most doctors genuinely want to help their patients and feel some kind of personal responsibility and thus, can easily be exploited by the healthcare system to work longer hours. If they don’t do it, patients die, because there is no one else taking care of these patients.

Just wanted to share that Cuba is the country with most "doctors per 10k people" with a ratio of 84.2 doctors. In comparison, USA has 26.1 and Australia 41. I just find it very interesting that Cuba has 300% more doctors than USA.

[1] Sorting by Latest available data (2020–2023 https://en.wikipedia.org/wiki/List_of_countries_and_dependen...

The answer is simple, mandatory limits on hours and days worked. Also fix healthcare regulation and the process of becoming a doctor so there isn't a supply shortage of doctors and surgeons.

aka The darker side of having people who wouldn't make it through the first four weeks of med school managing health services.

And they got MBAs instead.

There's been a critical spotlight on Australia's medical industry lately. Like gouging the medicare system or skirting regulations to profiteer off the insane demand for semiglutide weight loss drugs like Ozempic (couple of links below).

If you were a young, idealistic doctor (or an experienced idealistic doctor) I could imagine feeling incredibly disheartened when you see this kind of thing going on around you.

For the regulators I think the challenge they have is how to minimise the damage of the "bad" medical professionals (or weed them out of the system entirely) while not crushing the spirit of the good ones. I certainly don't know the answer.

https://www.abc.net.au/news/2024-04-08/price-of-pain-doctors...

https://www.abc.net.au/news/2024-04-01/cowboy-pharmacist-beh...

Also not that it really changes anything but the linked article says it was written in 2024, though Dr Bryant's death was in 2017: https://www.brisbanetimes.com.au/national/queensland/i-didnt...

The first things you talk about have nothing to do with the second things you talk about, but I can see how they can be lumped together.

The truth is the medical sector in Australia is always under intense scrutiny, and rightly so.

Currently the biggest systemic threat to our healthcare system (in my opinion) is underpayment/underinvestment in general practice which is having a critical effect on new trainees entering GP.

Dr Levi is a well known Melbourne ENT surgeon who has been extensively involved in doctor wellbeing initiatives, including starting Socks for Docs day. It looks like he just discovered substack and has started writing - I am sure I have seen this exact essay from him previously, which is where we get the discordance of him talking about the 2017 death as though it happened last week.

Doctors meet better unions in that country

Senior doctors in New Zealan have one of the most powerful unions in the country

Junior doctors are catching up

It is still a punishing career, but not like that.

In many countries doctors' unions actually encourage this sort of stuff, by restricting the number of spots in medical degrees. Making sure there are as few juniors as possible, making their life more miserable than it needs to be - this sort of stuff.

The goal of a union is to put a fence around the employers and drive wages up. Mission accomplished.

> The goal of a union is to put a fence around the employers and drive wages up

Feeding the troll: The role of a union is to represent the interests of their members

Fair enough, I'll revise my statement: the side effect of a union is to put a fence around the employers and drive wages up.

While you've identified their stated purpose, I can assure you after having been in multiple unions that they serve themselves first, then their members.

Yes

> I can assure you after having been in multiple unions that they serve themselves first, then their members.

The doctor's union for senior doctors in New Zealand is an exception to that rule.

I have had similar experiences as you with unions I have belonged to, but still, they were useful when I got into a dispute with those evil powerful people who had the power over me.

But you are not wrong

There’s a blurb underneath the title linking to third party page. This page is selling a really quacky looking book, that has no obvious connection to the author of this article.

Is this an ad? It doesn’t look like normal ad placement. It looks like the author of the article is promoting it.

And it seems really quacky.

I wish substack was clearer on whether this product is endorsed by the author of the article.

I always find it odd when I see doctors saying stuff like "I have a duty of care, so I work 24/7 if I need to." I dunno about doctors, but after 12 hours of work my mind is toast, and I wouldn't trust myself to operate a toaster. I find it really hard to imagine the same thing does not apply to them.

Is an absent doctor really worse than an exhausted one? I mean, there's obvious situations in which this is the case, but is it true on average? If someone arrives at the hospital and dies because there is no doctor available, only for that doctor to go and save 3 people that might have otherwise died the next day because they're not exhausted, should we make that tradeoff?

> I am realising more and more that what brings me greatest distress is the relentless administrative pressure which take away the meaningful clinical engagement I have with my patients. And I wonder if this is what many young doctors are experiencing as well. Medicine used to be a meaningful pursuit. Now it has become a tiresome industry. The joy, purpose and meaning of medicine has been codified, sterilised, protocolised, industrialised and regimented. Doctors are caught in a web of business, no longer a noble vocation. The altruism of young doctors have been replaced by the shackles of efficiency, productivity and key performance indicators.

tl;dr: professional feels like a proletarian.

If they didn't artificially restrict the supply of doctors the demand would be met.

The profession as a whole is profoundly hostile to any serious considerations of mental health, and it’s going to take many more suicides before even the smallest steps are taken toward obvious quality of life improvements.

humanity as a whole is profoundly hostile to any serious considerations of mental health. Dr. Drew once agreed with a rant by cohost adam carolla along the lines of (this is a whisper transcription. blame me for mistranscriptions, idc)

"It just doesn't make any sense to me. What's so bizarre in our culture, if you'd broken your leg when you were a kid and you needed a few years of physical therapy, you'd get it. You'd be running on it, and by the way, people would be applauding your great commitment that you go out and work out every day on your leg, and you make sure that you're going to overcome that problem, and you're going to get back up on skis again and whatever. The same thing is true with our brain, and somehow because it's our brain, no, no, no. Sorry. We'll have none of that. What would [...] tell you to do? Oh, he'd say just decide to change. You just gotta decide to change. You gotta get up, you gotta dust yourself off, you gotta take a long look in the mirror, and you gotta decide to change. I can't change for you, and all the people wishing you'd change around you aren't gonna make you change. There's only one person that can change your life, and that person's name is [...]. You want to lose weight, you're gonna have to burn more calories, and you're gonna... "

All true. I think doctors as possessors of the monopoly on health spending are uniquely positioned to fuck the whole society up with their own blindness to monumental aspects of health

This is what happens when the people doing the actual good work are looked at purely as a cost. The administration that is brought about to contain that cost will end up costing way more than any possible cost savings they could theoretically get. Putting the force of government behind that administration just makes it that much worse.

I see the same thing in tech. Engineers used to be empowered and productively making things that empowered everyone, and now they're disempowered, broken to the saddle of whatever the tech oligarchs are fancying today.

It's side point, but I'm wondering, why does the blog post start with a link to a book? It looks like an interesting book, but I don't see the relationship. Has Substack started running advertising?

Nextdoor neighbor is an orthopedic surgeon. He says it is basically impossible to clear your schedule in any meaningful way. You have to just push yourself to have balance and know that sometimes the high salary and not helping all the patients you want is a trade off to some work life balance. He looks exhausted sometimes but makes as much time for his family as he can.

It’s time to open more med schools and accept more doctors. Telling me a 27 instead of a 26 on the mcat makes you somehow a way better doctor is nonsense.

The sooner this type of job is automated the better imo. What’s the point of having people working so hard they end up dying?

Also I’ve suffered a misdiagnosis that ruined my life in my early years so it’s not like doctors are heroes either. We never hear about the failures only the successful stuff at the bleeding(heh) edge.

They make mistakes, they’re just humans.

Everyone glorifies their profession but what about the people who suffer misdiagnosis? Have to live the rest of their life in misery because of incompetence.

There was a philosopher who once wrote "all regimes exist under the consent of the governed." This should go double for the medical profession. They have the brains, the education--and in most cases, the money--to object, weather a fight if need be, and comfortably pivot if they lose. If the situation is intolerable, the person to blame is in the mirror. They are competitive people. The bureaucrats and administrators understand this, and use it to pull their strings--make them dance. Click. Click. Click.

I've aspired to become a doctor since I was a boy, I have managed to carve out a unique career out of medicine and I get to work at home and I have a lot of support, I spend hours working on what I love. I work with doctors who tell me I would make a great doctor. I think there is just too much resistance to getting into medical school.

Shouldn't the title be "The darker side of being a physician"?

A Doctor can be also a doctor of philosophy or something else. I am both a physician and a doctor, and I feel it is important to make a distinction. It's also as a respect to the PhDs who are usually in the traditional procession of the universities AHEAD of the medical doctors.

I think the doctor that commited suicide suffered from an acute depressive episode, so the outcome could be prevented by catching it early, taking a break etc

As a doctor myself, I believe it's difficult for a non-doctor to understand our problems. Saving lives (in quantity and quality) is both very rewarding and demanding but those two feelings cancel each other out, hopefully leaving a small positive residual. The effort is usually disconnected with it's financial reward (eg an easy, a-few-minutes case can be paid the same as another that devastated you) and that is inevitable. The medical administration, both public and private, is totally inefficient, if not provocative (eg providing 10 minutes for a whole patient visit so that the pay seems attractive).

In the end, I believe the doctor himself should take advantage of the degrees medical profession freedom, make some choices and/or navigate himself in the medical system in order to balance work, salary and life, starting from the specialty (eg surgeon vs internist etc) and continuing during his whole career.

"Medicine used to be a meaningful pursuit. Now it has become a tiresome industry. The joy, purpose and meaning of medicine has been codified, sterilised, protocolised, industrialised and regimented. Doctors are caught in a web of business, no longer a noble vocation. The altruism of young doctors have been replaced by the shackles of efficiency, productivity and key performance indicators."

That's textbook Marxist alienation of work. It was not supposed to happen to middle class workers though.

Oddly enough medicine has never been more regulated and financed by government so hard to say this is some sort of marxist dynamic, more like the consequences of centralization that happened after (because of) WWII. You see this in the US/UK/Canada regardless of whether they're "socialized" it's a mess everywhere.

> It was not supposed to happen to middle class workers though. Don't think Marx wrote or said that. Any source?

I meant the "Marxism was about 19th century factory workers, I'm middle class so it doesn't apply to me" line of thinking.

Psychiatrist here. What the author of the article describes sounds familiar to doctors in many specialties. Happily, I am not that far from retirement. You can't imagine how many burnt out doctors there are everywhere.

This can happen in any work.

But I concede, medicine is grueling - not worth the money if you ask me.

No sympathy from this software engineer/developer. Especially since i have seen burnout in my closest friends and mildly in myself.

Sunk cost fallacy is what keeps these doctors stuck. They get addicted to the lifestyle, income, and prestige after years low on the totem pole. The workload seems manageable until the reality of boundaries being crossed involves having to choose. We only have 24 hours in a day.

This is not just a medical industry issue. The tech industry is inherently prone to burnout when potential rewards can exceed even that of a doctor. I know too many stories of drug-induced burnout while trying to keep up a certain lifestyle. We all have a choice, and we need to check in with ourselves to make sure we are not losing more than we gain.

I wonder why this guy has a plug for that home doctor book which looks reeeeally sketchy. I went looking for reviews of it and reddit is filled by spam from just one reddit user

> I have lost control of my days. I had worked in a hospital where I was oncall 24/7, 12 days out of 14. I had fortnightly weekends off. When I was preparing for surgical exams, I’d be working and studying from 6.30am to 10pm everyday, seeing my family only on the weekends for lunch. I had worked in a hospital network that covered 4 campuses and drove 500kms a week when covering these sites. I had worked in a hospital where I didn’t get home for days at a time, sleeping overnight in hospital quarters, outpatient clinic benches and in my car.

We have to stop Medicare. It's not sustainable.

How would ending Medicare change the conditions in your quote?

Because the health care system is dramatically overwhelmed. There are not enough doctors for the demand.

What a weird way to frame the problem.

Why not increase the supply of doctors instead of reducing demand, whatever that means?

> Why not increase the supply of doctors instead of reducing demand, whatever that means?

Because that's not sustainable. We can't throw unlimited human resources at health care. We have other issues and societal problems to focus on.

We can only create so many doctors, because its expensive to lock down a smart and ambitious mind for so many years.

Opening up healthcare for free for old people is like opening up an untapped fire hose. This is insanity.

Has anyone ever to stopped to think what work life is like for these doctors and for other health care workers? These people should be able to have a social life, a family, and be able to live out there lives.

    We can only create so many doctors, because its expensive to lock down a smart and ambitious mind for so many years

How many smart minds do we have reinforcing addictive online behavior?

Nobody is saying to throw unlimited resources at it. They're saying to increase supply because there is currently a shortage.

Oooh, how about we do "Obamacare death panels" instead? I mean, that's basically what would happen if Medicare ceased to exist, anyway!

And that's because of Medicare? How do you figure?

See my comment here: https://news.ycombinator.com/item?id=40029190

Interested to know if this is also the situation in places where the medical care isn’t free/price-controlled/subsidised, as it is in Australia?

Another worst thing is that developed world sucks necessary doctors out of undeveloped world. No human right concerns whatsoever. UN as always useless

You are a body to the healthcare system. My wife is a hospice nurse and they're happy to grind you into the ground as long as it suits them.

as long as the client has money in their savings account*

It was depressing realizing that our medical system is ordered against the benefit of the two principals, the patient and the doctor.

Enforcing duration of medical actions must be some of the most idiotic things a healthcare MBA/MPH could come up with. Forcing a surgeon to finish surgery exactly within allocated time is putting lives at risk. The factory model should never be applied to fields like these.

Yes, not enough doctors. Allow more doctors seems like a good partial solution to the elite overproduction problem.

i was in the waiting room for surgery, sitting in front of the vending machine. i saw surgeons come out there to get their lunch from the vending machine. i thought about how hangry i can get trying to code around lunch time. also thought it was wrong that i got an hour lunch break and they don't.

People think doctors are some super human that they can heal themselves but they are people just like you and me. It's despicable that they along with veterans are being treated with ambivalence.

The most recent example of contempt towards doctors described in the article I've seen comes from South Koreans who enjoy a generous, affordable, high quality healthcare that exceeds those in North America complaining doctors make "too much" and that there isn't enough doctors.

Main problems: lack of public healthcare (and only being for-profit instead) and lack of government enforcements around public healthcare.

Same thing in the UK with dental (and Doctors); clinics prefer to take private patients over NHS patients because they make more money that way.

Easily solved, the government just needs to 1: require a certain number or threshold of accepted patients per week to be public (and any contacts are submitted with type to government to track, same as passport travel) 2: apply harsher labour laws to clinics to prevent them from forcing their staff to work ridiculous overtime to make more money and cover availability 3: allow more medical students and have no idiotic unfair restrictions.

Medical industries are critical to modern society and I definitely think that there should be no limited number of places, any student that passes entrance exams should get minor scholarships to help pay for/promote this position.

We're all important to the economy but at the end of the day all comes down to medical staff when any of us get sick, no matter which industry we work in ourselves.

Typical large amount HN uniformed comments where people espouse what they think and either don't or only lightly back up what they are saying in any meaningful way. Thinking there are just simple solutions to a very complex and entrenched issue.

This one hanging under the current top comment as an example:

"It's the same in the US, Italy, etc Doctors are a cartel receiving a monopoly from the State. That's all there is to it, really"

Forgetting the reasons (sure - it's all some grand program by the AMA et al to keep up current Physician pay) for a second thinking that if you can just churn them out like you do 'coders' with some quick program that doesn't require many many years of training and residency programs as well as hospitals and other infrastructure. And of course the cost to do all of this.

In almost typical HN fashion it's always a scam. Everyone else is getting away with being overpaid and undertaxed except top software engineers who of course deserve the pay they are getting.

The particular Physician in question is in Australia and is a surgeon. So you want to just be able to pluck people at random and give them a chance to be a surgeon as if there isn't something special that is required for that specialty.

Also, that Surgeon details some of his bad experiences but not how often that has happened. And doesn't even detail what he has done in terms of fixing it with the hospital administrators just continues to be a martyr getting beaten up by the system. Not claiming it's his job to try and get change at his hospital. But by the same token this idea that he has to do what he does or 'people will die' does not fly. Your own health and sanity is more important than that (as is your families).

I didn't even consider surgeon as an option. The idea of a life being dependent on my steady hand, skill and knowledge is terrifying. Literally I'm having a bad day, mess up, someone dies?

...having people brave enough to take that on drown in red tape is a shameful black mark on society.

Especially since the Covid vaccine return to some normalcy for many of us, always in the back of my mind whenever dealing with healthcare providers, is that they're probably the ones that both survived and stuck through that catastrophe.

And, some places, I get the impression they have fewer staff now, and greater financial challenges.

> If I decide to work less, who is going to cover the hospital? If the hospital aren’t employing other doctors, we can’t allow patients to go uncovered. I accept the fact that I have a duty of care to be on call.

The hospital also has a duty of care.

It seems the two better solutions are either government financed hospitals, which are always hopelessly overpatient but as a doctor you are more free, because they usually don't get paid much and anyone who works in a gov hospital is upmost welcome. And the other option are overpriced private hospitals where you don't have so much financial pressure.

"Patient satisfaction officers, Theatre Utilisation officers, Patient Flow Coordinators. These are all business roles" Forget all this nonsense the man who saves lives is the surgeon and doctor. People are very grateful to the people who actually save their life.

The shit we make doctors go through is unnecessarily insane. It takes 300-400k of debt and grueling 7-8 years on top of a bachelors degree, with bunch of uncertainty on where you'll be or whether you ever make it, just to start working. If you ever quit before then, any progress made counts for zero and you have to start all over again in a new field with a ton of debt.

Why doesnt an MD or even credits at a medical school count toward nursing, physician assistsnt, etc?

Lastly, med school is unnecessarily long. You don't need most of the material to do family medicine for example.

I really don't understand how such inefficiencies could be tolerated.

I agree but the education system is starting to improve. Some schools now offer combined Baccalaureate-MD programs which can reduce the education time by up to 2 years.

https://students-residents.aamc.org/medical-school-admission...

Tennessee now allows some physicians to practice without completing a residency program, largely as a way to attract immigrants to work in underserved communities.

https://www.medscape.com/viewarticle/993693

Have doctor’s unions helped before?

Why would they? Did pilot's unions campaign for strict rules regarding pilot's working hours? Or was it the FAA/CAA/etc. that did it?

The shocking side of becoming a doctor: https://en.wikipedia.org/wiki/This_Is_Going_to_Hurt

A medical student keeps a journal, becomes a doctor, hates his life, publishes his journal. One post I am laughing my ass off, the next I am in tears. It changed my perspective entirely and I recommend anyone read it.

"We hoped our machines would automate our work and make us free. Instead they turned us into automatas."

lol people took "Uber" too seriously. There is a privilege problem that is exacerbating a climate problem. I blame the tech industry and its lust to disrupt.

Capitalism alienates us all.

TL;DR capitalism kills doctors.

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